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Overview

Overview. Definitions Cholera: clinical, epidemiology History and pandemics Peru: diary of Cholera’s epidemic Environmental factors Cholera today Conclusion. New insights on the emergence of Cholera in Latin America during 1991: the Peruvian experience. C Seas, J Miranda, AI Gil, et. al.

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Overview

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

  2. 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

  3. 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%)

  4. 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 concentrationsorin viable state but not cultivatable

  5. 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

  6. 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

  7. 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

  8. Cases Compatibles DatePlace Distance (Km) 23 Oct 90 Trujillo (*) 570 11 Dec 90 Chimbote 440 24 Dec 90 Trujillo 26 Dec 91 Chancay 60 29 Dec 90 Trujillo 13 Jan 91 Lima 0 16 Jan 91 Chancay 1050 23 Jan 91 Epidemic’s official beginning (*) Cases identified were from two different hospitals

  9. Discussion (i) • Majority of infections are asymptomatic • V. choleraeis 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

  10. Discussion (ii) • Suggest V. Choleraewas 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

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

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

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

  14. en

  15. 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

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

  17. 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

  18. 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

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