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Cholera rarely occurs in children under 2 years of age. We describe diarrhea due to Vibrio cholerae 0139 Bengal, the newly described etiologic agent of cholera in a 4-day-old breast-fed baby. However, the diarrhea was mild and was successfully treated with rehydration therapy and erythromycin.

In 1849 John Snow, already the leading anaesthetic practitioner and innovator of his day, made a historic contribution to the epidemiology of infectious disease by his famous study of the distribution of cholera around the area of Broad Street in London. We report on our experience as anaesthetists in a field hospital, dispatched as part of the international rescue effort to Goma, Zaire, to help combat the effects of cholera among the Rwandan refugees.

The National Program for Maternal and Child Health (COSMI) of the Ministry of Health (MOH) of Brazil conducted a survey in nine state capitals from 29 March to 30 April 1993 to assess how well health facilities were managing diarrhea cases in patients under 5 years of age. One of seven PAHO/WHO health facility surveys performed in Latin America and the Caribbean in 1992-1993, the Brazilian survey took place in the Northeast Region where most diarrheal morbidity and mortality occur. Like the other six surveys, it used a new PAHO/WHO methodology designed to collect data on certain principal indicators through observation, interviews, and review of clinical records. Overall, 475 cases of patients with diarrhea were observed in 192 facilities, and 463 health workers and 474 caretakers were interviewed. The results indicated that few diarrhea patients received care that strictly followed the PAHO/WHO/Ministry of Health treatment guidelines. In terms of these guidelines, the correct procedure was used to assess the patient's hydration status only 8% of the time, and only 1% of the health workers provided correct advice to the caretaker on prevention and home care aspects of diarrheal diseases. The procedure used to rehydrate patients with oral rehydration salts (ORS) was correct in only 6% of the cases. Of those patients with bloody stools, 24% were treated appropriately with antibiotics. Besides collecting information on correct case management, the survey provided a basis for developing two-year operational plans of action in each of the nine participating states to strengthen efforts directed at controlling and preventing diarrheal diseases, including cholera.

We describe septicemia due to Vibrio cholerae 0139 Bengal, the newly described causative agent of cholera, in a child who also had simultaneous intestinal infection with Shigella boydii. Because V. cholerae 0139 is capsulated, its propensity to cause extraintestinal infection is stressed.

Clinical profile of cholera was studied in children attending Diarrhea Training and Treatment Unit from January-December 1993. Out of a total 8714 cases of acute watery diarrhea, 64 children (0.7%) were suspected to have cholera on the basis of acute onset loose water/rice watery stools, high purge rate with or without excessive vomiting and/or severe dehydration. Stool culture was positive for cholera in 33 cases (51.6%). All the isolates were V. cholerae 01 biotype El Tor serotype Ogawa. Sixty four per cent of stool culture positive cases were below 5 years of age. The results assume importance because out of 28 children < 2 years with clinical suspicion of cholera, 11 cases (39.3%) were culture positive for V. cholerae, youngest child being 3 months old. Comparison of various parameters revealed that presence of vomiting > 4 episodes/ day (p < 0.005), frequency of stools >12/24 hours (p <0.002), rice watery stools (p < 0.01) and presence of severe dehydration (p < 0.01) were significant parameters associated with positive stool culture. Beside examination of stool sample by hanging drop method was an excellent diagnostic tool (p < 0.001) with a sensitivity of 51.5%, specificity 100% and positive predictive value of 100%. The isolates of V. cholerae were susceptible to furazolidone, cephelexin, nalidixic acid, norfloxacin and gentamicin. Our observations indicate that cholera is not uncommon in infants and young children. Like children in the older age group, acute onset diarrhea with watery/rice watery stools and high purge rate with or without excessive vomiting and/or rapid development of severe dehydration should arouse suspicion of cholera in younger children also. They should be investigated for cholera even in non-endemic areas and in the absence of cholera outbreaks.

The response to oral immunisation of humans with classical biotype cholera toxin B subunit was studied to identify immunodominant T lymphocyte determinants. The in vitro proliferative response to pools of 12-mer peptides and larger peptides used individually was analysed by a novel statistical approach, and identified an immunodominant region in residues 70-79 in immunised subjects, when either pools or individual peptides were employed. In contrast, a patient infected with El Tor biotype had a dominant response to residues 40-60. The statistical software employed in this study may enable efficient screening of antigens for immunodominant T lymphocyte determinants when blood precursor frequencies are low following immunisation, and may therefore be of special relevance to mucosal vaccines.

Cholera remains a threat to human health in many parts of the world, including the United States. The epidemiology of cholera is reviewed to prepare for identification and prevention of the disease in appropriate clinical settings. The clinical manifestations of cholera and the pathophysiology of the toxin-induced diarrhea are reviewed to introduce and to clarify appropriate therapeutic and preventive interventions.

Materials on the import of rarely occurring Vibrio cholerae, not belonging to group O1 of serovar O139, to the territory of Russia are presented. The clinical picture of a cholera case is described and the biological properties of V. cholerae, serovar O139, are presented. A suggestion has been made concerning the appearance of a new V. cholerae serovar, capable of ousting V. cholerae eltor, the cause of the seventh pandemic.

Doctor Felipe Castillo, head of the Hospital de San Pablo during the cholera epidemic of 1850, used "Salty water" as treatment for the patients who attended the hospital. The etiology and pathogenesis of this sickness were unknown in those days, so Castillo's conduct was surprising. This study is based on an unpublished report, classified as anonymous, that Castillo gave to the Governor of Mexico City during the cholera epidemic.

Background: On the basis of human perfusion studies it has been speculated that bicarbonate ions in oral rehydration salt solutions (ORS) to treat diarrhoea are more efficiently absorbed from the small bowel. We evaluated the role of bicarbonate in ORS by using a reduced purging rate in cholera as a proxy indicator for absorption efficiency in cholera-like severe diarrhoea., Methods: In a double-blind randomized trial 60 patients received standard ORS containing bicarbonate or an identical solution except that sodium bicarbonate was replaced by an equimolar amount of sodium chloride (sodium, 90 mmol/l; potassium, 20 mmol/l; chloride, 80 mmol/l; bicarbonate, 30 mmol/l; glucose, 111 mmol/l; and osmolality, 331 mmol/l) after initial intravenous rehydration to correct initial dehydration and shock and until diarrhoea ceased., Results: Five patients receiving standard ORS and eight receiving bicarbonate-free ORS required unscheduled intravenous therapy for recurrence of severe dehydration in spite of receiving ORS solution. ORS intake and purging rate, in ml/kg body weight/day, both including and excluding stool output during unscheduled intravenous therapy are closely similar in the two treatment groups., Conclusion: The results indicate that bicarbonate-containing ORS solution does not have any clinically significant effect on the absorption efficiency of ORS, either beneficial or adverse, and its use is relevant only for correction of metabolic acidosis of diarrhoeal dehydration.

In July, 1994, in one of the worst cholera outbreaks in recent times, an estimated 12,000 Rwandan refugees died in Goma in eastern Zaire. The Vibrio cholerae strains were resistant to tetracycline and doxycycline, the commonly used drugs for cholera treatment. Despite the efforts of international organisations, which provided medical relief by establishing treatment centres in Goma, mortality from the disease was much higher than expected. In the area of Muganga camp, which had the largest concentration of refugees and where most of the medical aid organisations were active, the highest reported case-fatality ratio for a single day was 48%. The slow rate of rehydration, inadequate use of oral rehydration therapy, use of inappropriate intravenous fluids, and inadequate experience of health workers in management of severe cholera are thought to be some of the factors associated with the failure to prevent so many deaths during the epidemic. In one of the temporary treatment centres with the worst case-fatality record, our team showed that improvement of these factors could increase the odds of survival of cholera patients even in a disaster setting.

In this paper an object-oriented system for the storing and the managing of epidemiological data in order to decrease the incidence of a given groups of diseases by means of health care strategy application and of the relative health care resource allocation is described. The system starts from the present epidemiological situation of the territory examined and from the real distribution on this territory of human and material health care resources. The health care manager inputs the available budget, some information regarding the population living on this area, other geographical and climatic informations, the values of certain epidemiological parameters of the diseases considered--the system has stored the mathematical and departmental models of these diseases--and the system allocates (using own allocation algorithms) human and material health care resources, optimizing the cost-benefit rate.

Glucose-based oral rehydration salt (ORS) is an appropriate and cost-effective tool to treat diarrhoeal dehydration. In patients with a high purging rate, particularly due to cholera, rice-based ORS has been shown to substantially reduce stool output compared to glucose ORS. However, it is not used in the hospitals or diarrhoea treatment centres largely because of the non-availability of a ready-to-use inexpensive packaged product and because of the problem of cooking. In a large diarrhoea treatment centre in Bangladesh (with an annual ORS consumption of approximately 140,000 litres), we have maintained in-house production of rice ORS and used it routinely for more than 600,000 patients over the last nine years. Semi-literate health workers cook rice ORS and supervise mothers in its use. Rice ORS is less costly (US $0.15 per patient treated compared with US $0.37 for glucose ORS) and is well accepted. It is an attractive alternative to glucose ORS in many fixed facility treatment centres in countries where rice is a staple and cholera is endemic. The process of its in-house preparation and use is described in this report which may assist hospitals wishing to use rice ORS in treating diarrhoea patients. Availability of a low cost ready-to-use rice ORS packet (which needs no cooking) with adequate shelf-life will increase its use at fixed facilities.

Objective: To assess cholera recognition and treatment by US health care workers in the largest cholera outbreak in the United States this century., Design: We reviewed the medical records of passengers from a flight on which a cholera outbreak occurred. To determine the availability of oral rehydration solutions, we surveyed treatment facilities and referral pharmacies., Setting: On February 14, 1992, more than 100 passengers on a flight from South America to Los Angeles, Calif, were infected with toxigenic Vibrio cholerae O1., Subjects: Fifty-four of 67 passengers who sought care in California and Nevada., Results: We reviewed the records of 54 passengers, including 39 with diarrhea and 15 without symptoms. All 17 persons who sought treatment before the outbreak was widely reported by the media had diarrhea. For 12 of these persons, recent travel to South America was noted, but only those four whose records listed cholera as a possible diagnosis were immediately hospitalized. Seven sought care again within 3 days; three were dehydrated, two of these three were hospitalized, and one of these two died. None of the 26 patients suspected to have cholera received appropriate fluids; severely dehydrated patients did not receive Ringer's lactate solution and those not severely dehydrated did not receive an oral rehydration solution. None of the facilities and pharmacies involved stocked World Health Organization oral rehydration salts solution, the preferred solution for treating cholera and other diarrheal diseases., Conclusions: Treatment of cholera in the United States was suboptimal. Oral fluids appropriate for the treatment of cholera and other diarrheal diseases were generally unavailable. Widespread cholera in the developing world means that US physicians should be prepared to treat "imported" cases. Physicians evaluating patients with diarrhea should obtain a travel history, should consider cholera in patients returning from countries with endemic or epidemic cholera, and should instruct patients in appropriate use of World Health Organization oral rehydration salts solution or other oral rehydration solutions containing 75 to 90 mmol/L of sodium. Pharmacies and medical facilities should stock these solutions.

A household survey in 1991, at the onset of the Latin American cholera epidemic, investigated high attack rates in Trujillo, Peru, and determined the association between blood group O and severe cholera. Of 463 persons in 69 households, 173 (37%) reported diarrhea, 21% required rehydration therapy, and 4% were hospitalized; these treatment requirements greatly exceeded estimates based on other populations. Elevated vibriocidal or antitoxic antibody titers were present in 52% of 321 from whom serum was obtained; 73% were blood group O. Blood group O was strongly associated with severe cholera: Infected persons had more diarrheal stools per day than persons of other blood groups, were more likely to report vomiting and muscle cramps, and were almost eight times more likely to require hospital treatment. Since prevalence of blood group O in Latin America may be the world's highest, estimates of treatment requirements should be increased to prevent unnecessary deaths.

The etiology, epidemiology, pathogenesis, clinical manifestations and treatment procedures of cholera with the point to new experience are presented. This work was motivated by the intensifying interest for this old disease which has reappeared in Europe in epidemic form.

Since 1961 cholera has spread in many countries reaching a pandemic form. Since 1991 Mexico has been involved in this pandemia. Near 20% of all cases of cholera in our country happen in fertile women, so the possibility of the association between cholera and pregnancy is high. We present the case of a pregnant woman, who during her third trimester presented a episode of cholera, developing premature labor. Furthermore is revised the medical literature about the general principles of the management of cholera, and the association between pregnancy and the intestinal infection.

Within 24 hours of returning from a five-week holiday in Pakistan a 15-year-old girl developed vomiting and massive diarrhoea leading to severe dehydration with hypovolaemic shock. The diastolic blood pressure was no longer measurable and prerenal renal failure occurred with a serum creatinine of 4.4 mg/dl and metabolic acidosis (pH 7.21, base excess-16.9 mmol). Initially treatment consisted of rehydration (day 1: 9280 ml, day 2: 4850 ml). The patient's condition rapidly improved and she had voluminous stools. A concurrent urinary infection due to Klebsiella pneumoniae was first treated with cotrimoxazole. As a new strain of Vibrio cholerae, serogroup O 139, was isolated from stool, treatment was changed to tetracycline (50 mg/kg daily). Regaining a good general state she was transferred to an isolation ward on the 6th hospital day. The isolated cholera organism belongs to a nonagglutinating serogroup which is indistinguishable clinically and epidemiologically from the classical Vibrio strains which cause cholera. Since the end of 1992 this new serogroup has been causing an explosive spread of cholera in Bangladesh and India.

We describe the disease spectrum and socio-demographic and epidemiological features of an epidemic of cholera due to a new pathogen, Vibrio cholerae O139, in patients attending a very large hospital in the metropolitan city of Dhaka, Bangladesh. This hospital treats 70,000-90,000 patients a year with diarrhoeal diseases. A 4% systematic sample of 1854 patients attending from January to April 1993 were studied. Five hundred and two (27%) of the 1854 patients were culture positive for V. cholerae O139 and 63 (3%) were culture positive for V. cholerae O1 biotype El Tor. Patients with V. cholerae O139 were mainly adults with a short history of watery diarrhoea. Eight-three percent of patients had moderate to severe dehydration. All recovered except one 80-year-old man with compromised renal function who died. Seventy-eight percent of patients required initial intravenous rehydration followed by oral rehydration therapy with rice ORS; they also received tetracycline to reduce diarrhoea severity. Most patients were from urban slums with inadequate sanitation facilities and hygiene practices. The newly recognized V. cholerae O139 infection produced an epidemic of severe dehydrating diarrhoea indistinguishable from clinical cholera in a population which experiences two epidemic peaks of cholera in a year due to V. cholerae O1. Infection with the latter does not appear to confer any cross-protection from V. cholerae O139. The new pathogen suppressed, albeit temporarily, V. cholerae O1. Unlike other non-O1 serogroups of V. cholerae this new serogroup appears to have epidemic potential.

Clinical analysis was carried out of El Tor cholera in 100 patients, plasma concentrations of electrolytes of potassium (K) and sodium (Na) were studied as were those of trace elements of iron (Fe), copper (Cu), magnesium (Mg) and manganese (Mn) in the whole blood before and after rehydration therapy and depending on the extent of dehydration. The results were as follows: the plasma concentration of K and Na was lowered, that of Mg in the whole blood increased in stage III as well as that of Mn in st. I and II of dehydration; the concentration of Fe, Cu was decreased in st. I, II, III, and of Mn in sit. III of dehydration. The activities of transferrin and ceruloplasmin were found to be on the decrease for the duration of the illness. Rehydration promoted the return to normal of water and electrolyte metabolism, haemodynamics, without affecting to any noticeable degree the trace element metabolism.

It is not known why the cholera epidemic, which affected all other continents, has not affected Latin America in the past 30 years. In addition, it is unclear why cholera appeared in Peru in 1991. Improvements in scientific knowledge and technology have occurred in Peru during the last 30 months. While it is impossible to summarize in only one article all these concepts, this article presents a few of the most important issues and recent developments in the treatment and prevention of cholera.

A retrospective review was conducted of the clinical histories of 43 pregnant women treated for acute diarrheal disease in the emergency ward of the María Auxiliadora Departmental Hospital (HADMA) in Lima, Peru, and 32 of the histories were selected for this study. These 32 patients had been admitted to the cholera treatment unit (CTU) of the HADMA for acute choleraic diarrhea with moderate or severe dehydration. The objective was to analyze the clinical evolution of the patients, their response to isotonic rehydration therapy (0.9% saline solution), and the consequences for their pregnancies. The following variables were examined: age; trimester of pregnancy; heart rate and mean blood pressure (MBP) at admission; number of hours since last normal urination; duration of diarrhea; degree of dehydration; volume of diarrhea and vomiting; volume of saline solution administered in the first 2 hours and in total; volume of multi-electrolyte solution (MES) or oral rehydration salts (ORS) administered from the second to the sixth hour and in total; and hours between admission to the emergency ward and transfer to the cholera treatment unit (EME/CTU). Logistic regression analysis revealed a direct and statistically significant correlation between the time of recovery of diuresis and the EME/CTU (P = 0.001; r = 0.65), as well as between time of recovery of diuresis and the volume of diarrhea in the first 4 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Mouse monoclonal antibodies (MAbs) were derived against acetone-treated whole cells of the newly recognized Vibrio cholerae O139 serogroup which is causing epidemics of cholera-like disease in India and Bangladesh. Four MAbs specifically recognized the lipopolysaccharide antigens of V. cholerae O139. MAbs ICL9 and ICL13 were of the immunoglobulin M (IgM) isotype, ICL11 was of the IgG3 isotype, and ICL12 was of the Ig2b isotype. A fifth MAb, ICL10, of the IgG2b isotype cross-reacted with V. cholerae O91. All five MAbs recognized V. cholerae O139 in an enzyme-linked immunosorbent assay, slide agglutination test, motility inhibition test, and indirect immunofluorescence test. During a 1-month evaluation of these MAbs in our clinical laboratory, all 86 cases diagnosed as V. cholerae O139 by a rabbit polyclonal antiserum were also detected by these MAbs, establishing their utility as highly sensitive and specific diagnostic reagents. With these MAbs, it should now be possible to screen for the V. cholerae O139 serogroup in epidemic and endemic diarrhea cases and in environmental and food samples.

We present the case of a 31-year-old Peruvian female with severe dehydration due to diarrhea and vomiting. The patient was one of a number of travelers arriving in Los Angeles on an international flight from Argentina and Peru. Because of the travel history and clinical presentation, cholera was suspected and ultimately confirmed by stool culture. The patient's clinical course is outlined, and discussion of the relevant epidemiology and clinical management of cholera is provided. Physicians should suspect cholera when treating patients with severe gastroenteritis. The short incubation period, rapid onset of dehydration and shock, and high case fatality rate of untreated cholera require a consideration of cholera in patients with diarrhea and recent travel to areas where cholera is prevalent.

Cholera is an acute intestinal infection caused by Vibrio cholerae 01. When an infected person presents severe dehydration and is not adequately treated, he or she will develop hypovolemic shock and eventually could died. There is scarce information concerning this disease in the Pediatric group. Herein we report on eight cases of Pediatric cholera, in children 17 month to four years of age. Seven patients out of eight were admitted presenting dehydration. Four presenting mild or moderate dehydration and three presenting hypovolemic shock. These three patients were rehydrated by intravenous route and thereafter the hydration was maintained by oral therapy. The outcome was uneventful in six patients. One patient developed abdominal distention probably due to hypopotassemia, and another patient presented hyponatremia and seizures. All the patients recovered within five days after admission.

Vibrio cholerae non-O1 has previously been isolated only occasionally in Norway from patients infected abroad. This report describes the clinical course in two patients who were domestically infected with V. cholerae non-O1. In one case, contaminated seafood, i.e. crab, was the probable source of infection. Both patients displayed a cholera-like type of illness, with severe diarrhoea and electrolyte disturbances. It is recommended that Norwegian laboratories be prepared to isolate vibrios also in domestically infected cases when watery diarrhoea is present.

Cholerae is a grave and acute bacterial intestine infection which is caused by a bacilo, V. cholerae 01, that produces toxic products. Its clinical symptoms range from abundant liquid diarrhoea combined with vomiting and rapid dehydration. It is highly lethal when right treatment is not applied. There are also cases of cholera where victims do not show any symptoms of it, that is asymptomatic carriers. Any clinical suspicion of cholerae has to be corroborated by epidemiological data and its diagnostic confirmation should be done by isolating the bacteria, V. cholerae. When beginning the treatment, it is not necessary to confirm the diagnostic and this is based on the restitution of the liquids lost through vomiting and facing using any methods that are recommended for any other type of diarrhoea. The antimicrobial treatment is used only for grave cases. This present revision includes recent knowledge about cholerae emphasising on the effective management of cases through an adequate use of right treatment methods and also using the principal prevention measures against dissemination of this disease.