EPIDEMIOLOGY AND DYNAMICS OF CHOLERA IN PAKISTAN
INTRODUCTION
Cholera is a preventable and treatable communicable infectious disease still remains a
significant threat to public health particularly in developing countries of Asia and Africa.[1]
Cholera remains a significant public health concern, particularly in area with
inadequate sanitation and water infrastructure. According to the World Health
Organization, an estimated 1.3 to 4 million cases of cholera occur each year resulting in
21000 to 143000 deaths globally. Cholera outbreaks can occur in both developing and
developed countries, emphasizing the importance of surveillance, prevention and response
measures.[2]
EPIDEMIOLOGY
Cholera is endemic in Pakistan, but has never been considered, a significant cause of
diarrhea before 1971. In 2011 world health organization calculated total annual and age-
specific incidence of cholera from diseases of the most impoverished (DOMI) cholera
surveillance programs in Kolkata-India, jakarta-indonesia, and Beira-Mozambique
Kolkata’s incidence rates were applied to countries of the Eastern Mediterranean Region
(EMR) in WHO mortality stratum D (EMR-D), which includes Pakistan, Somalia and other
countries with a large cholera burden .Total annual incidence was estimated to be
1.64\1000, highest amongst infants 7.16\1000, followed by 7.01\1000 in 1-4 years,
2.19\1000 in 5 to 14 years.
As cholera is amongst notifiable disease a number of cases of cholera and deaths are
reported to World Health Organization by the ministry of health, Pakistan published
weekly epidemiological record. Highest number of cholera cases and deaths were reported
in 1971 (1185 cholera cases and 43 deaths), 1993(12092 cases and 206 deaths) and in
2011 (527 cholera cases and 219 deaths). Cholera is distinctive among diarrheal diseases
in that mortality is high among patients of all ages. Data reported showed that cases fatality
rate of cholera varies from 3.63-41.56 during 1970-2012.[3]
Cholera is a seasonal disease occurring mostly during rainy season. However,
studies conducted in Pakistan showed seasonality of vibrio (v.) cholera infection have been
reported in both rainy and dry season.[4]
There is paucity of data on the spatial distribution of cholera outbreaks in Pakistan.
Available studies and reports published shows that outbreaks of cholera are sporadic and
distributed over wide geographical locations. A study was conducted in 2010 based on the
genomic analysis of all v. cholerae to identify the population dynamics and transmission of
v. cholera in Pakistan after 2010 floods.[5]
CAUSES AND TRANSMISSION
Cholera is primarily caused by ingestion of food or water contaminated with the bacterium
vibrio cholerae. The bacteria can survive in contaminated water sources, particularly in
area with poor sanitation and inadequate access to clean drinking water. Cholera is
commonly spread in areas affected by natural disasters, such as floods or earthquakes
where water and sanitation system are disrupted.[2]
RISK FACTORS
In Pakistan, although individual level factors like age and gender are commonly studied
risk factors, information about other socio-demographic factors such as socio-economic
and educational status in lacking, in addition behavioral practices like frequency of hand
washing, practice of garbage disposals and maintenance of hygiene and sanitation in and
around household has never been studied in Pakistan. Vibrio cholerae infection is known to
be more severe in individuals suffering from malnutrition.[6]
Multitude of environmental factors has influence on the diversity, distribution, incidence
and severity of cholera. These environmental factors can be classified as proximal or distal
determinants, proximal environmental determinants including climate change
deforestation, urbanization, road projects, and agricultural practices that has influence on
distal environmental determinants such as fecal contamination of water through affecting
population density, water salinity and water flow rate, wind speed and population
migration.
This is either because of better employment opportunities or most probably due to natural
disasters affecting villages in Pakistan. Unplanned migration of population has influence on
the transmission of infectious diseases by affecting population density creating burden on
existing infrastructure of water and sanitation system. Inadequate environmental
management due to lack of basic infrastructure and non-availability of water and sanitation
system, poor hygiene, contamination of food, unplanned human settlement, especially in
urban and peri-urban slums, absences of effective health system, inadequate health care,
poverty and recent natural disasters disrupting water and sanitation system, or the
replacement of population to inadequate and overcrowded camps are the factors for
responsible outbreaks of cholera.[7]
PATHOPHYSIOLOGY
Cholera is mainly caused by two pathogenic serotypes of V. cholerae: O1 and O139. The
pathogenesis underlying acute diarrheal illness is as follows:
V. cholerae is usually transmitted via the fecal-oral route to the human host. Following ingestion,
the V. cholerae must overcome host defense mechanisms such as gastric acidity, intestinal
inhibitory factors, and changes in temperature and osmolarity.
Infective dose varies from 102-106.
The incubation period varies from a few hours to a few days. After gaining access to small intestine,
V. cholerae uses flagella to propagate through the mucus layer covering small intestine and
colonizes the small intestinal cells using toxin-coregulated pilus (TCP) forming a biofilm.
Diarrheal illness in human host is mainly caused by production of enterotoxin.
The production of enterotoxin protein in the small intestinal cells is the main mechanism
responsible for causing acute diarrheal illness.
It has 5B subunits and 2A subunits.
B subunits bind the enterocytes via GM1 ganglioside receptors and cause internalization of A
subunits in the cells via endocytosis.
Subunits then bind and activate the adenylate cyclase enzyme in the enterocytes, increasing the
levels of cAMP.
Increased levels of enterotoxin cause activation of the cystic fibrosis transmembrane conductance
regulator (CFTR), causing increased secretion of water, sodium, and chloride from enterocytes,
which causes watery diarrhea.
The different virulence factors involved in the pathogenesis of V. cholerae involve activation of
transcription factors such as ToxR, TcpP, and ToxT. Different toxins expressed by these
transcription factors include:
Zona occludens toxin (zot, causes invasion by decreasing intestinal tissue resistance)
Accessory cholera toxin (ace, increases fluid secretion)
Toxin-coregulated pilus (tcpA, essential colonization factor and receptor for the CTXf phage)
NAG-specific heat-labile toxin (st)
Outer membrane porin proteins (ompU and ompT).[8]
DIAGNOSIS
Cholera is diagnosed by analyzing by stool sample to detect the presence of vibrio cholerae
bacteria. Rapid diagnostic tests are available in some settings, enabling quick identification
of the disease cholera.
TREATMENT
Cholera treatment focuses on rehydration and antibiotics to combat the infection. Oral
rehydration salts (ORS) or intravenous fluids are administrated to replenish lost fluids and
electrolytes. Antibiotics such as doxycycline or azithromycin maybe prescribed to reduce
the duration and severity of symptoms. In severe cases intravenous fluids and
hospitalization may be required.
CONTROL AND PREVENTION
Preventing cholera involves improving sanitation and assesses to clean water. This
includes promoting proper hygiene practices such as hand washing with soap and safe food
handling.
Vaccines are available to protect against cholera, and oral cholera vaccines can be
administrated in high risk area or during outbreaks, when cholera outbreaks occur, swift
response is crucial to prevent further transmission and reduce the impact. This includes
establishing treatment centers providing assess to clean water and sanitation facilities,
conducting community awareness campaigns, and implementing measures to ensure safe
food practices. International organization such as world health organization and
humanitarian agencies, often support affected countries in outbreak response efforts.[2]
CONCLUSION
Cholera remains a major cause of morbidity and mortality particularly among susceptible
individual in Pakistan. The paper attempts to take into account of available literature and
researches on cholera in Pakistan. Disease is endemic in Pakistan as many other countries
of south Asia, Africa, South America and Central America as there is no disease free period
from 1995 to 2010 with the severe under reporting of cholera cases by the government to
world health organization. Most of the available studies are of poor quality focused on
changing epidemiology pattern of prevalent biotype and serotype of vibrio cholerae over
years and environmental and socio-cultural factors and a casual related and help in
explaining the outbreaks of cholera in Pakistan has never been explored. This situation
warrants further research that could help in designing potential intervention and
formulated policies to reduce burden of cholera in Pakistan.
REFERENCES
[1]. Seas c, Gotuzzo E. Cholera: overview of epidemiologic, therapeutic, and preventive
issues learned from recent epidemics. Int J Infect Dis 1996; 1:37-46.
[2]. Chat.openai.com.
[3]. Mohammad A. The global burden of cholera. Bull World Health Organ 2012; 90:209-18.
[4]. Alam M. Seasonal variation in bacterial pathogens isolated from stool samples in
Karachi, Pakistan. J Pak Med Assoc 2003; 53:125-9.
[5]. Shah MA. Genomic epidemiology of vibrio cholerae o1 associated with floods, Pakistan,
2010. Emerg Infect Dis 2014; 20:13.
[6]. Rafi S, Hussain A, Saeed W, Ali A, Khawaja SA. Changing epidemiology and sensitivity
pattern of vibrio cholerae at Rawalpindi. Pak J Med Sci 2004; 20:357-60.
[7]. Bezirtzoglou C, Dekas K, Charvalos E. Climate changes, environment and infection:
Facts, scenarios and growing awareness from public health community within Europe
Anaerobe 2011; 17:337-40.
[8]. WWW.WIKIDOC.ORG
