# Cholera

cholera

infectious disease| Has cause | Vibrio cholerae  |
| Health specialty | infectious diseases, emergency medicine  |
| Medical examination | physical examination, microbiological culture, complete blood count, rapid diagnostic test, polymerase chain reaction  |
| Possible treatment | oral rehydration therapy, intravenous fluid replacement, Antibiotics and Chemotherapy, vaccine  |
| Disease transmission process | food-borne transmission, fecal–oral route, water-borne transmission  |
| ICD-9-CM | 001.0, 001, 001.9  |
| Subject named as | Cholera  |

**Cholera** be an infection of de small intestine by sam strains of de bacterium *Vibrio cholerae*. Symptoms fi range from none, to mild, to severe. De classic symptom be large amounts of watery diarrhea wey dey last a few days. Vomiting den muscle cramps sanso fi occur. Diarrhea fi be so severe wey e dey lead within hours to severe dehydration den electrolyte imbalance. Dis fi in turn result in sunken eyes, cold anaa cyanotic skin, decreased skin elasticity, wrinkling of de hands den feet, den, in severe cases, death. Symptoms dey start two hours to five days after exposure.

Cholera be caused by a number of types of *Vibrio cholerae*, plus sam types wey dey produce more severe disease dan odas. E be spread mostly by unsafe water den unsafe chow wey be contaminated plus human feces wey dey contain de bacteria. Undercooked shellfish be a common source. Humans be de only known host give fe bacteria. Risk factors for de disease dey include poor sanitation, insufficient clean drinking water, den poverty. Cholera fi be diagnosed by a stool test, anaa a rapid dipstick test, although de dipstick test be less accurate.

Prevention methods against cholera dey include improved sanitation den access to clean water. Cholera vaccines wey dem dey give by mouth dey provide reasonable protection for about six months, den confer de added benefit of protecting against anoda type of diarrhea wey *E. coli* cause. Insyd 2017, na de US Food and Drug Administration (FDA) approve a single-dose, live, oral cholera vaccine dem call Vaxchora give adults aged 18–64 wey dey travel to an area of active cholera transmission. E dey offer limited protection to young kiddies. People wey survive an episode of cholera get long-lasting immunity for at least three years (de period dem test).

De primary treatment give affected individuals be oral rehydration salts (ORS), de replacement of fluids den electrolytes by using slightly sweet den salty solutions. Rice-based solutions be preferred. Insyd kiddies, na dem sanso find zinc supplementation to improve outcomes. Insyd severe cases, intravenous fluids, such as Ringer's lactate, fi be required, den antibiotics fi be beneficial. De choice of antibiotic be aided by antibiotic sensitivity testing.

Cholera dey continue to affect an estimated 3–5 million people worldwide den dey cause 28,800–130,000 deaths a year. To date, seven cholera pandemics occur, plus de most recent dey begin insyd 1961, den dey continue today. De illness be rare insyd high-income countries, wey e dey affect kiddies most severely. Cholera dey occur as both outbreaks den chronically insyd certain areas. Areas plus an ongoing risk of disease dey include Africa den Southeast Asia. De risk of death among those wey be affected usually be less dan 5%, dem give improved treatment, buh fi be as high as 50% widout such access to treatment. Na dem find descriptions of cholera as early as de 5th century BCE insyd Sanskrit literature. Insyd Europe, na dem initially use cholera as a term to describe any kind of gastroenteritis, wey na dem no use am give dis disease til de early 19th century. Na de study of cholera insyd England by John Snow between 1849 den 1854 lead to significant advances insyd de field of epidemiology secof ein insights about transmission via contaminated water, wey na a map of de same be de first recorded incidence of epidemiological tracking.
Di main symptoms of cholera na serious diarrhea and vomiting of clear water-like fluid. These symptoms dey usually start suddenly, like half day go reach five days after person chop (ingest) the bacteria.

The diarrhea dey often describe am as “rice water” type, and e fit even get fishy smell. Person wey no receive treatment for cholera fit dey pass about 10 to 20 litres (3 to 5 US gal) of diarrhea every day.

Serious cholera, if no treatment, fit kill about half of di people wey e affect. If di heavy diarrhea no get treatment, e fit cause life-threatening dehydration and imbalance of electrolyte for body.

Estimates of people wey get infection but no show symptoms (asymptomatic) compare to those wey dey sick (symptomatic) don range from 3 to 100.

Cholera dem dey also call am “blue death” because person skin fit turn bluish-gray as body dey lose plenty fluid too much.
Fever no dey common, and if e show, e fit mean say secondary infection don join. Patients fit become very weak or sleepy (lethargic), and dem fit get sunken eyes, dry mouth, cold and sweaty skin, or wrinkled hands and legs.

Kussmaul breathing, wey be deep and heavy breathing style, fit happen because of acidosis from loss of stool bicarbonate and lactic acidosis wey come from poor blood flow (perfusion).

Blood pressure dey drop because of dehydration, while pulse for body dey fast but weak (thready). Urine wey person dey pass go reduce as time dey go on.

Muscle cramps and weakness, confusion or changed awareness, seizures, and even coma fit happen because of electrolyte imbalance—this one dey happen plenty especially for children.

1. 1. Cause

Scanning electron microscope image of *Vibrio cholerae*
*Vibrio cholerae*, di bacteria wey dey cause cholera
1. 1. 1. Transmission

Transmission of cholera dey happen usually through fecal-oral route, meaning say contaminated food or water wey come from poor sanitation dey carry am pass enter person body.

For developed countries, most cholera cases dey come from contaminated food, while for developing countries e dey mostly come from water.

Cholera bacteria fit dey inside shellfish and plankton. Food transmission fit happen when people harvest seafood like oysters from water wey sewage don contaminate, because *Vibrio cholerae* dey gather inside small water organisms like planktonic crustaceans, and oysters dey chop those organisms.

Cholera outbreaks dey increase in frequency, spread, and intensity because of climate change.

People wey get cholera dey pass watery diarrhea, and this stool (wey people dey call “rice-water”) fit contaminate water wey other people dey use.

One single diarrhea event fit increase the number of *V. cholerae* for environment by one million times.

The contamination source usually be people wey get cholera, especially when dem no treat their diarrhea and e enter water bodies, groundwater, or drinking water systems. Drinking contaminated water or eating food wey dem wash with that water, or eating shellfish from infected water, fit cause infection.

Cholera rarely dey spread directly from person to person.

*V. cholerae* also fit survive outside human body for natural water sources, either alone or together with phytoplankton, zooplankton, or dead organic and inorganic matter.

Drinking such water fit still cause infection even without human fecal contamination. However, environmental conditions fit reduce how strong the bacteria be.

Both toxic and non-toxic strains dey exist. Non-toxic strains fit later become toxic through bacteriophage infection.

1. 1. 1. Susceptibility

Normally, about 100 million bacteria must enter body before cholera fit start for healthy adult. But this amount reduce for people wey get low gastric acid, like those wey dey use proton pump inhibitors.

Children dey more vulnerable, especially ages two to four. Blood group also dey affect risk—people with type O blood dey more likely to get infection.

People with weak immune system, like those with AIDS or malnourished children, fit suffer severe cholera if dem get infected.

Even healthy adults still fit get severe case, so each case must be monitored based on fluid loss with help from health professionals.

The genetic mutation linked to cystic fibrosis (delta-F508) fit actually give some protection. People wey carry one copy of the gene (heterozygous carriers) dey more resistant to *V. cholerae* infection.

For this model, the defect for ion channel protein (cystic fibrosis transmembrane conductance regulator) dey interfere with how bacteria dey attach to intestine lining, so e reduce infection effect.

## Mechanism

The role of biofilm in the intestinal colonization of Vibrio cholerae
When person drink or swallow cholera bacteria, most of the bacteria no survive the strong acidic condition inside human stomach.

The few wey survive go conserve energy and stored nutrients by shutting down protein production as dem dey pass through the stomach. When dem reach the small intestine, dem must pass through thick mucus layer before dem fit reach the intestinal wall where dem go attach and grow.

Once Vibrio cholerae reach the intestinal wall, dem no need flagella again for movement. So dem stop producing flagellin protein in order to conserve energy and nutrients by adjusting the proteins dem dey express based on new environment.

On reaching the intestinal wall, Vibrio cholerae start produce toxic proteins wey cause watery diarrhea in infected person. This watery stool carry new generations of bacteria go outside body into drinking water if sanitation no dey proper.

The cholera toxin (CTX or CT) na protein complex made of six subunits: one A subunit and five B subunits connected by disulfide bond. The B subunits form ring shape wey fit bind GM1 ganglioside receptors on intestinal epithelial cells. The A1 part of A subunit na enzyme wey dey ADP-ribosylate G proteins, while A2 chain fit into B-ring structure.

After binding, the toxin enter cell through receptor-mediated endocytosis. Inside cell, disulfide bond break, and A1 subunit release to interact with ADP-ribosylation factor 6 (Arf6).

This activation make permanent modification of Gs alpha subunit of heterotrimeric G protein, leading to continuous production of cyclic AMP (cAMP). This cause secretion of water, sodium, potassium, and bicarbonate into intestinal lumen, resulting in severe dehydration.

The gene for cholera toxin enter Vibrio cholerae through horizontal gene transfer, usually carried by CTXφ bacteriophage.

Scientists study how gene expression change as bacteria pass through stomach, mucus layer, and intestinal wall.

Inside intestine, regulatory proteins TcpP/TcpH and ToxR/ToxS activate ToxT, which turn on virulence genes responsible for toxin production and colonization.

## Genetic structure

Vibrio cholerae strains from pandemics show genetic variation. Two main clusters exist: Cluster I and Cluster II. Cluster I include older strains from 1960s and 1970s, while Cluster II contain strains from 1980s and 1990s, especially from Africa.

## Antibiotic resistance

In many parts of the world, cholera bacteria don develop resistance to antibiotics. For example, in Bangladesh, many cases resist tetracycline, trimethoprim-sulfamethoxazole, and erythromycin.

Scientists have developed diagnostic methods to detect multi-drug resistant strains quickly.

New antibiotics have also shown effectiveness against Vibrio cholerae in laboratory studies.
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## Diagnosis

File:Rapid diagnostic test strip.jpgA rapid dipstick test fit show whether Vibrio cholerae dey present
There be rapid dipstick test wey doctors fit use check if Vibrio cholerae bacteria dey inside sample. If the test come back positive, doctors go do further testing to check whether the bacteria don develop resistance to antibiotics.

For epidemic situation, doctor fit diagnose cholera just by asking patient history and doing quick physical examination. Treatment like rehydration therapy and oral hydration solutions fit start even before laboratory confirmation, especially for places where cholera dey common.

Stool samples and swab samples wey collect early during sickness (before antibiotics start) na the best samples for laboratory diagnosis. If cholera outbreak dey suspected, the most common bacteria wey cause am na Vibrio cholerae O1.

If Vibrio cholerae serogroup O1 no show, laboratory go check for Vibrio cholerae O139. But if neither O1 nor O139 show, then stool sample must go reference laboratory for further investigation.

Any infection with Vibrio cholerae O139 must be reported and treated same way like O1 cholera cases. Any diarrheal disease from this bacteria dey classified as cholera and must be reported, especially for places like United States. Cholera mainly be risk for developing countries, especially areas where access to WASH (water, sanitation and hygiene) infrastructure no dey good enough.

If sanitation practices dey properly introduced and followed quick, e fit stop outbreak. There be different points for cholera transmission chain where dem fit block the spread:

* Sterilization: Proper disposal and treatment of all things wey fit contact stool of cholera patient (like cloth, bedsheet, etc.) dey very important. Dem suppose wash am for hot water and if possible use chlorine bleach. Anybody hand wey touch patient or their things must wash am well and disinfect am with chlorinated water or other strong antimicrobial agents.

* Sewage and fecal sludge management: For areas wey cholera dey, sewage and fecal waste need proper treatment so e no spread disease through human waste. Good sanitation and hygiene dey very important. Open defecation, release of untreated sewage, or dumping of fecal sludge from pit latrine or septic tank into environment must stop. For many cholera areas, sewage treatment no dey enough. So dry toilet wey no need water and no dey cause water pollution fit be better option than flush toilet.

* Sources: Make people put warning for water sources wey fit be contaminated, plus instruction on how to clean water (like boiling or adding chlorine) before dem use am.

* Water purification: Any water wey people go drink, cook or wash with suppose be treated well. Dem fit boil am, use chlorine, ozone treatment, ultraviolet light, or filter am well. Boiling and chlorination be cheap and effective way to stop spread. Cloth filter or sari filter too fit reduce cholera well for poor communities like for Bangladesh. Better modern filters dey even more effective. Health education and proper hygiene practice dey very important.

WHO Africa still recommend say people suppose wash hand with soap or ash after toilet and before dem chop food or handle food to prevent cholera.

* Dumping of sewage or fecal sludge from UN camp into lake near Port-au-Prince dey believed say e help spread cholera after Haiti earthquake for 2010, wey kill many people.
* Example of urine-diverting dry toilet for cholera-affected area for Haiti. This type of toilet stop disease spread through fecal-oral route because e no dey pollute water.
* Cholera hospital for Dhaka, showing normal cholera treatment beds.

### Surveillance

A modelling approach using satellite data can help improve how we fit predict cholera risk areas for different parts of the world.
Surveillance and quick reporting dey very important to control cholera outbreaks fast. Cholera dey behave like seasonal disease for many countries wey get am, especially during rainy season. Surveillance system fit give early warning about outbreak, so authorities fit respond quick and prepare well. Good surveillance also help to know where risk dey high so prevention fit target the right places. For prevention to work well, cases must dey reported to national health authorities.

### Vaccination

Euvichol-plus oral vaccine for cholera
Spanish doctor Jaume Ferran i Clua develop the first successful cholera vaccine for 1885, the first wey immunize people against bacterial disease. E vaccine work but e cause controversy and some people no accept am at that time. But later e prove say e dey effective: from 30,000 people wey e vaccinate, only 54 die. Russian-French scientist Waldemar Haffkine too develop cholera vaccine for 1892. E run big vaccination program for British India.

People wey survive cholera fit get immunity for at least 3 years. Some safe oral vaccines dey available for cholera prevention. WHO get three approved oral cholera vaccines: Dukoral, Sanchol, and Euvichol. Dukoral be inactivated oral vaccine wey get about 52% protection for first year and 62% for second year, with few side effects. E dey available for more than 60 countries. But CDC no still recommend am for most travelers from United States go endemic countries. US FDA vaccine called Vaxchora be oral live vaccine wey fit protect adults 18–64 years after single dose.

Injectable vaccine dey too, e fit protect person for 2–3 years, but e work less for children under five years old. But as of 2010, availability still limited. Work still dey go on to study mass vaccination role. WHO recommend say high-risk people like children and HIV patients for endemic countries suppose receive vaccine. If vaccination cover many people, herd immunity fit reduce cholera spread for environment.

WHO still talk say oral cholera vaccine fit be used for endemic areas, outbreak response, or humanitarian crisis where risk high. OCV dey useful for different situations but no full agreement still dey on how to use am everywhere.

### Sari filtration

Women for village pond for Matlab, Bangladesh, dey wash utensils and vegetables. Woman for right dey put sari filter for water container to filter water for drinking.
For Bangladesh, people develop simple method called sari filter to reduce contamination of drinking water. Dem dey use old sari cloth (best one) or other cloth. Used cloth dey work better than new one because washing am many times reduce space between fibers. Water wey dem filter like this get fewer germs, so e safer pass before. For Bangladesh, this method reduce cholera cases by almost half. Dem dey fold sari 4 to 8 times. After use, dem suppose rinse am and dry am under sun to kill bacteria. Nylon cloth fit also work but e cost more and no easy to get.

## Prevention

Preventive inoculation against cholera in 1966
World Health Organization (WHO) dey advise say make people focus on prevention, preparedness, and response to control how cholera dey spread. Dem still emphasize say strong surveillance system dey very important. Governments get role for all these areas.

### Water, sanitation and hygiene

Although cholera fit kill person, preventing am dey usually easy if proper sanitation practices dey followed well. For developed countries, because dem get better water treatment and sanitation systems, cholera no dey common. For example, the last big cholera outbreak for United States happen for 1910–1911. Cholera mainly be risk for developing countries, especially areas where access to WASH (water, sanitation and hygiene) infrastructure no dey good enough.

If sanitation practices dey properly introduced and followed quick, e fit stop outbreak. There be different points for cholera transmission chain where dem fit block the spread:

* Sterilization: Proper disposal and treatment of all things wey fit contact stool of cholera patient (like cloth, bedsheet, etc.) dey very important. Dem suppose wash am for hot water and if possible use chlorine bleach. Anybody hand wey touch patient or their things must wash am well and disinfect am with chlorinated water or other strong antimicrobial agents.

* Sewage and fecal sludge management: For areas wey cholera dey, sewage and fecal waste need proper treatment so e no spread disease through human waste. Good sanitation and hygiene dey very important. Open defecation, release of untreated sewage, or dumping of fecal sludge from pit latrine or septic tank into environment must stop. For many cholera areas, sewage treatment no dey enough. So dry toilet wey no need water and no dey cause water pollution fit be better option than flush toilet.

* Sources: Make people put warning for water sources wey fit be contaminated, plus instruction on how to clean water (like boiling or adding chlorine) before dem use am.

* Water purification: Any water wey people go drink, cook or wash with suppose be treated well. Dem fit boil am, use chlorine, ozone treatment, ultraviolet light, or filter am well. Boiling and chlorination be cheap and effective way to stop spread. Cloth filter or sari filter too fit reduce cholera well for poor communities like for Bangladesh. Better modern filters dey even more effective. Health education and proper hygiene practice dey very important.

WHO Africa still recommend say people suppose wash hand with soap or ash after toilet and before dem chop food or handle food to prevent cholera.

* Dumping of sewage or fecal sludge from UN camp into lake near Port-au-Prince dey believed say e help spread cholera after Haiti earthquake for 2010, wey kill many people.
* Example of urine-diverting dry toilet for cholera-affected area for Haiti. This type of toilet stop disease spread through fecal-oral route because e no dey pollute water.
* Cholera hospital for Dhaka, showing normal cholera treatment beds.

### Surveillance

A modelling approach using satellite data can help improve how we fit predict cholera risk areas for different parts of the world.
Surveillance and quick reporting dey very important to control cholera outbreaks fast. Cholera dey behave like seasonal disease for many countries wey get am, especially during rainy season. Surveillance system fit give early warning about outbreak, so authorities fit respond quick and prepare well. Good surveillance also help to know where risk dey high so prevention fit target the right places. For prevention to work well, cases must dey reported to national health authorities.

### Vaccination

Euvichol-plus oral vaccine for cholera
Spanish doctor Jaume Ferran i Clua develop the first successful cholera vaccine for 1885, the first wey immunize people against bacterial disease. E vaccine work but e cause controversy and some people no accept am at that time. But later e prove say e dey effective: from 30,000 people wey e vaccinate, only 54 die. Russian-French scientist Waldemar Haffkine too develop cholera vaccine for 1892. E run big vaccination program for British India.

People wey survive cholera fit get immunity for at least 3 years. Some safe oral vaccines dey available for cholera prevention. WHO get three approved oral cholera vaccines: Dukoral, Sanchol, and Euvichol. Dukoral be inactivated oral vaccine wey get about 52% protection for first year and 62% for second year, with few side effects. E dey available for more than 60 countries. But CDC no still recommend am for most travelers from United States go endemic countries. US FDA vaccine called Vaxchora be oral live vaccine wey fit protect adults 18–64 years after single dose.

Injectable vaccine dey too, e fit protect person for 2–3 years, but e work less for children under five years old. But as of 2010, availability still limited. Work still dey go on to study mass vaccination role. WHO recommend say high-risk people like children and HIV patients for endemic countries suppose receive vaccine. If vaccination cover many people, herd immunity fit reduce cholera spread for environment.

WHO still talk say oral cholera vaccine fit be used for endemic areas, outbreak response, or humanitarian crisis where risk high. OCV dey useful for different situations but no full agreement still dey on how to use am everywhere.

### Sari filtration

Women for village pond for Matlab, Bangladesh, dey wash utensils and vegetables. Woman for right dey put sari filter for water container to filter water for drinking.
For Bangladesh, people develop simple method called sari filter to reduce contamination of drinking water. Dem dey use old sari cloth (best one) or other cloth. Used cloth dey work better than new one because washing am many times reduce space between fibers. Water wey dem filter like this get fewer germs, so e safer pass before. For Bangladesh, this method reduce cholera cases by almost half. Dem dey fold sari 4 to 8 times. After use, dem suppose rinse am and dry am under sun to kill bacteria. Nylon cloth fit also work but e cost more and no easy to get.

## Epidemiology

Cholera dey affect about 2.8 million people worldwide, and e dey cause around 95,000 deaths every year (uncertainty range: 21,000–143,000) as of 2015.

This thing dey happen mainly for developing countries.

For early 1980s, dem believe say death rate still dey pass three million people every year. E dey hard to calculate exact number of cases because many no dey report am, especially when outbreak fit affect tourism for a country. As of 2004, cholera still dey both epidemic and endemic for many parts of the world.

Recent big outbreaks include the 2010s Haiti cholera outbreak and the 2016–2022 Yemen cholera outbreak. For October 2016, cholera outbreak start for war-torn Yemen. World Health Organization (WHO) call am “the worst cholera outbreak in the world”. For 2019, 93% of all reported 923,037 cholera cases come from Yemen (with 1911 deaths reported). Between September 2019 reach September 2020, global total case pass 450,000 and deaths pass 900; but numbers no dey fully accurate because some countries dey report suspected cases instead of confirmed ones, while others no dey report at all like Bangladesh, India and Philippines.

Even though we sabi plenty things about how cholera dey spread, scientists still no fully understand why outbreak dey happen for some places and no dey happen for others. Poor sanitation and lack of safe drinking water dey make am spread well-well. Rivers and water bodies fit carry the bacteria as reservoir, and seafood wey travel far fit also spread am. Cholera cases dey increase during both flood and drought times pass normal periods.

Cholera don disappear from Americas for most part of 20th century, but e come back near the end, start from Peru outbreak. Later e continue with 2010s Haiti cholera outbreak and another outbreak during 2018–2023 Haitian crisis. As of August 2021, disease still dey endemic for Africa and some parts of East and West Asia (like Bangladesh, India and Yemen). For Europe, cholera no dey endemic; all cases dem report am come from people wey travel go endemic areas.

### History of outbreaks

File:Il cholera di Palermo del 1835.jpg|thumb|upright=1.3|Body disposal of people wey die during cholera epidemic for Palermo in 1835
File:Africa cholera2008b.jpg|thumb|upright=1.3|Map of 2008–2009 cholera outbreak for sub-Saharan Africa showing statistics as of 12 February 2009

The word cholera come from Greek word χολέρα (kholera), from χολή (kholē) wey mean “bile”. Cholera likely start for Indian subcontinent, because e don dey there for many centuries.

References to cholera appear for European writings as far back as 1642, from Dutch doctor Jakob de Bondt description in his book De Medicina Indorum. At that time, Europeans dey use word “cholera” for any serious diarrhea wey dey yellow. So de Bondt use the same word describe new disease. Later, around 1830s, people begin differentiate am from “cholera morbus” and “Asiatic cholera” (wey come from India).

Early outbreaks for Indian subcontinent happen because of overcrowding, poor living conditions, and stagnant water wey make bacteria grow well. Disease begin spread through trade routes go Russia in 1817, then Europe, North America, and other parts of world. Because of that, people start call am “Asiatic cholera”. Seven cholera pandemics don happen since 19th century; first one no reach Americas. Seventh pandemic start from Indonesia in 1961.

First cholera pandemic start for Bengal region near Calcutta between 1817 and 1824. E spread go Southeast Asia, Middle East, Europe, and Eastern Africa. Movement of British army and navy ships help spread am across Indian Ocean, Africa, Indonesia, China and Japan.

Second pandemic run from 1826 to 1837, affect North America and Europe. Better transport and trade plus migration make disease spread fast.

Third pandemic start in 1846 and end in 1860, reach North Africa and both North and South America. Irish immigrants bring am enter Canada during Great Famine.

Fourth pandemic run from 1863 to 1875, start from India go Naples and Spain, then reach USA via New Orleans in 1873. E spread through Mississippi River system.

Fifth pandemic (1881–1896) start for India go Europe, Asia, and South America. Sixth (1899–1923) reduce deaths because medicine don improve. Countries like Egypt, Arabia, Persia, India and Philippines suffer badly. Germany and Naples also get serious outbreaks.

Seventh pandemic start in 1961 for Indonesia, and new strain called El Tor appear and still dey persist as of 2018. E reduce around 1975 but never fully disappear, cases rise again for 1990s till today.

Cholera become big global disease in 19th century and don kill millions of people. For Russia alone, between 1847 and 1851, more than 1 million people die. It kill about 150,000 Americans during second pandemic. Between 1900 and 1920, about 8 million people die for India.

Cholera become first reportable disease for United States. John Snow for England in 1854 first show say contaminated water be the source of transmission. Today cholera no be big threat for Europe and North America again because of clean water systems like filtration and chlorination, but e still affect developing countries.

Before, ships dey fly yellow quarantine flag if cholera dey onboard. Anybody for ship no go land until about 30–40 days.

People for old times believe plenty traditional cures. Some think say bad air (miasma theory) dey cause am. Some also believe cold body fit make person more vulnerable, so dem use flannel and cholera belts. For Naples outbreak (1854–1855), people use homeopathic camphor.

Mother's Remedies book talk say tomato syrup dey help. Elecampane also dey used for UK. First vaccine come in 1885, and first antibiotic come in 1948.

Cholera cases reduce for developed countries because of better sanitation and treatment. But in 19th century America, cholera still serious problem. E spread through rivers like Erie Canal and Mississippi system. New York City also suffer because water system no strong enough then.

Cholera morbus be old term wey people use for gastroenteritis, not actual cholera disease.

* Drawing of Death bringing cholera, Le Petit Journal (1912)
* Emperor Pedro II of Brazil visiting cholera patients in 1855
* New York City Board of Health hand bill, 1832 — old advice show say people no understand disease well

### Research

One big breakthrough for cholera fight come from doctor John Snow (1813–1858), wey in 1854 link cholera to contaminated water. He also propose microbial cause in 1849 and prove say sewage contamination be main source for outbreaks in London in 1854. Today people call am Father of Epidemiology.

Bacterium wey cause cholera isolate in 1854 by Filippo Pacini, but people no really recognize am that time. Others like Joaquim Balcells i Pascual also report am same year.

Between 1850s and 1900s, developed countries invest heavily for clean water and sewage systems, and that reduce cholera outbreaks. In 1883, Robert Koch identify Vibrio cholerae as bacteria cause of cholera.

Hemendra Nath Chatterjee, Bengali scientist, first show oral rehydration therapy (ORS) work for cholera diarrhea. In 1953, he publish paper for The Lancet.

Indian scientist Sambhu Nath De discover cholera toxin and prove how bacteria dey transmit disease.

Robert Allan Phillips also develop rehydration protocol during research in Southeast Asia and win Lasker award in 1967.

More recent research for 2002 show say Vibrio cholerae change inside human body and become more infectious before e comot through stool, helping am survive for environment.

### Global Strategy

For 2017, WHO start global plan called “Ending Cholera: a global roadmap to 2030” wey aim reduce cholera deaths by 90% by 2030. Global Task Force on Cholera Control dey lead am and dey support countries with plans and monitoring.

The plan get 3 main goals: early detection and response, stopping transmission through sanitation and vaccines, and global coordination through GTFCC.

WHO no believe say cholera fit totally disappear worldwide because bacteria fit survive for environment even without human. But human-to-human transmission fit still be eliminated in some places.

Haiti example show say local elimination fit work, even though outbreak happen there before. Some countries still dey target full elimination certification.

GTFCC dey focus on 47 countries, and 13 of them don already start vaccination campaigns.

* Prevention and control of cholera outbreaks: WHO policy and recommendations
* Cholera – World Health Organization
* Cholera – *Vibrio cholerae* infection – Centers for Disease Control and Prevention