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Cholera should be considered as a risk for travellers returning to industrialized countries
Travel Medicine and Infectious Disease (2005) 3, 161–163
www.elsevierhealth.com/journals/tmid
SHORT COMMUNICATION
Cholera should be considered as a risk for travellers returning to industrialized countries Per Arne Parment* ¨gen 63, S-167 75 Bromma, Sweden Parment and Parment Medicinska Konsulter HB, Nockebyva Received 24 September 2004; received in revised form 12 October 2004; accepted 14 October 2004 Available online 7 January 2005
Cholera is an acute infection of the intestine, caused by a toxin producing strain of Vibrio cholerae, resulting in profuse watery diarrhoea. Without adequate treatment cholera can lead to shock and death within a few hours. Several pandemics have spread from the Ganges delta through Asia, Europe and the Americas in the 19th century. The seventh pandemic by Vibrio cholera serogroup 01 Biotype El Tor is now in progress and has been affecting countries in Africa, Asia and South America.1 Another type, Vibrio cholerae serogroup O139, have emerged in India and Bangladesh in 19922 and have been reported to been spread to other south east Asian countries, but even in these countries the O1 type still dominates. In 2003 111,575 cholera cases and 1894 cholera deaths were reported to the WHO from 45 countries.3 However, WHO considers that due to fear of trade sanctions and damage to tourism only 5–10% of the cholera cases are reported.4 Obviously cholera is a great problem in countries with poor sanitation, poor standards of food and water, and where wars have created large groups of refugees. For example, during the refugee crisis in Goma, Zaire in 1994 an estimated 58,000–80,000
* Tel.: C46 8808508. E-mail address: [email protected].
cases of cholera and 23,800 deaths occurred within 1 month.5 Most international travellers have the opportunity to be careful concerning food and water, but there is still a risk to catch cholera. However, the so called ‘back-packer tourists’, aid workers and people visiting friends and relatives are considered to be at greater risk than ordinary tourists for infection by cholera. Only a few cases of Cholera are imported to the European countries, with the exception of the UK (England and Wales), where an average of slightly more than 30 cases/year have been reported (17–48 cases/year 1995–2003).6 However, only a minority of them were for various reasons verified at the ESYV Reference Unit, Health Protection Agency, Colindale Avenue, London.7 (T. Cheasty, personal communication, 2004). Most UK cases are from the Indian subcontinent. Only 5–10% of cholera-infected persons do have the classical cholera gravis symptoms, but for these individuals there could be at risk of very severe disease. Previously healthy persons have developed in a few hours life-threatening symptoms. In 2003 a traveller died of cholera in Platte County, Nebraska just upon arrival.8 In 2004, a non-vaccinated 40-year-old Swedish male traveller fell ill during air-travel with severe watery diarrhoea, and was in hypovolemic shock with renal failure when he arrived to the airport.
1477-8939/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2004.10.001
162 However, his life could be saved due to prompt intensive medical care.9,10 Similar cases have been reported from Germany, where three men fell ill with severe watery diarrhoea, hypovolemic shock, and renal failure during a visit to a well known resort in Kenya, and a fourth man fell ill after returning home.11 In June of this year, a woman travelling from India to Europe fell ill on the air-flight between London and Brussels, and was taken to hospital with hypo-volemic shock upon arrival to the airport.12 There have been reports of travellers who have acquired cholera at popular holiday destinations as Phuket island in Thailand.13,14 However, 90–95% of the cholera cases are associated with mild symptoms or no symptoms at all. A number of patients with travellers’ diarrhoea could therefore be cases of mild cholera. The high numbers of imported cholera cases reported from Japan could be attributed to the intensive surveillance performed in that country.15,16 The good quality of the water and sewage system in the western counties will probably protected from spread of cholera from asymptomatic carriers, as long as these systems works properly. However, Dr Markku Kuusi of the National Public Health Institute in Finland, lists a numbers of waterborne outbreaks of different micro-organisms both in his own countries as in other Nordic Countries, England, Wales and the United States, due to failure of the water systems.17 Had the water sources been contaminated with cholera, instead of other bacteria as, e.g. Campylobacter, the result could have been disastrous. A greater risk for spread of cholera from asymptomatic carriers is food-handlers, and a number of such events are described in the literature.18–23 Since April 2004, an oral cholera vaccine (Dukoral) in approved in the countries of the European Union. This vaccine had been marked in Sweden since 1991. It has been tested in field trials in Bangladesh. The protection efficacy of the vaccine in the overall population was 85% for the initial 6 months of follow-up.24 Similar results were obtained in a study conducted among military recruits in Peru during the cholera epidemic.25 It is my opinion that we are morally obliged not to miss the opportunity to add vaccine protection to the important hygienic advice that we give to travellers. Author disclosure. Dr Per Arne Parment, is partner of a medical consultation firm, which has had assignments for SBL Vaccines and Solvay Pharmaceuticals.
P.A. Parment
References 1. Barua D. The global epidemiology of cholera in the recent years. Proc R Soc Med 1972;65:423–8. 2. Ramamurthy T, Garg S, Sharma R, et al. Emergence of novel strain of Vibrio cholerae O139 synonym Bengal. Lancet 1993; 342:387–90. 3. WHO. Cholera, 2003. Weekly Epidemiol Record 2004;79: 281–8. 4. WHO. Cholera vaccines. WHO position paper. Weekly Epidemiol Record 2001;76:117–24. 5. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire in July 1994? Lancet 1995;345:339–45. 6. www.hpa.org.uk/infections/topics_az/noids/annualtab. htm. Accessed 21september 2004. 7. www.hpa.orguk/infections/topics_az/cholera/menu.htm. Accessed 21 September 2004. 8. ProMED-mail USA (Cholera imported); 2003. 13. 20031007.2513 http://www.promedmail.org. Accessed 6 October 2004. 9. Hjertqvist M. Indienresena ¨r insjuknade i kolera. EPI-aktuellt 2004;3(16):2004. 10. Insulander M, Svenungsson B. Kolera efter Indienvistelse. Informationsbladet, Smittskyddsenheten, Stockholms la ¨ns landsting No 2; 2004. p. 3. 11. Kiehl W. Cases of cholera imported to Germany from Kenya. Eurosurveillance Weekly 1998;2(6). 12. ProMED-mail. An imported case of cholera in Brussels. ProMED-mail; 2004. 14.20040628.1726 http://www.promedmail.org. Accessed 6 October 2004 13. Anonymus. Man returns from Thailand carrying cholera. The Japan Times online Aug 22, 2001. http://www.japantimes. co.jp. Accessed 6 October 2004 14. Anonymus. Fallbericht zu aus Thailand importierter Cholera in Hamburg. Robert Koch—Institut. Epidemiologisches Bulletin 2004;25:198–9. 15. Wittlinger F, et al. Risk of cholera among western and Japanese travelers. J Travel Med 1995;2:154–8. 16. Sanchez JL, Taylor DN. Cholera. Lancet 1997;349: 1825–30. 17. Kuusi M. Investigating outbreaks of waterborne gastroenteritis. Application of modern epidemiological and microbiological methods. Helsinki: National Public Health Institute; 2004. 18. Tilak VW, Bhalwar R, Ratti JS. Epidemiological study of an outbreak of cholera in Delhi cantonment. Ind J Public Health 1997;41:61–7. 19. Goh KT, Lam S, Kumarapathy S, Tan JL. A common source foodborne outbreak of cholera in Singapore. Int J Epidemiol 1984;13:210–5. 20. Singh J, Bora D, Sharma RS, Khanna KK, Verghese T. Epidemiology of cholera in Delhi—1992. J Trop Pediatr 1995;41:139–42. 21. Swaddiwudhipong W, Akarasewi P, Chayaniyayodhin T, Kunasol P, Foy HM. A cholera outbreak associated with eating uncooked pork in Thailand. J Diarrhoeal Dis Res 1990; 8:94–6. 22. Savel’ev VN, Beliaev EN, Monisov AA, Kiuregian AA, Grizhebovskii GM. The cholera outbreak in one of the central regions of Dagestan [Article in Russian]. Zh Mikrobiol Epidemiol Immunobiol 1995;(Suppl. 2):52–6.
Cholera should be considered as a risk for travellers returning to industrialized countries 23. Lasch EE, Abed Y, Marcus O, Shbeir M, El Alem AA, Ali Hassan N. Cholera in Gaza in 1981: epidemiological characteristics of an outbreak. Trans R Soc Trop Med Hyg 1984;78:554–7.
163
24. Clemens JD, et al. Field trial of cholera vaccines in Bangladesh. Lancet 1986;2:124–7. 25. Sanchez JL, et al. Protective efficacy of oral wholecell/recombinant-B-subunit cholera vaccine in Peruvian military recruits. Lancet 1994;344:1273–6.
www.elsevierhealth.com/journals/tmid
SHORT COMMUNICATION
Cholera should be considered as a risk for travellers returning to industrialized countries Per Arne Parment* ¨gen 63, S-167 75 Bromma, Sweden Parment and Parment Medicinska Konsulter HB, Nockebyva Received 24 September 2004; received in revised form 12 October 2004; accepted 14 October 2004 Available online 7 January 2005
Cholera is an acute infection of the intestine, caused by a toxin producing strain of Vibrio cholerae, resulting in profuse watery diarrhoea. Without adequate treatment cholera can lead to shock and death within a few hours. Several pandemics have spread from the Ganges delta through Asia, Europe and the Americas in the 19th century. The seventh pandemic by Vibrio cholera serogroup 01 Biotype El Tor is now in progress and has been affecting countries in Africa, Asia and South America.1 Another type, Vibrio cholerae serogroup O139, have emerged in India and Bangladesh in 19922 and have been reported to been spread to other south east Asian countries, but even in these countries the O1 type still dominates. In 2003 111,575 cholera cases and 1894 cholera deaths were reported to the WHO from 45 countries.3 However, WHO considers that due to fear of trade sanctions and damage to tourism only 5–10% of the cholera cases are reported.4 Obviously cholera is a great problem in countries with poor sanitation, poor standards of food and water, and where wars have created large groups of refugees. For example, during the refugee crisis in Goma, Zaire in 1994 an estimated 58,000–80,000
* Tel.: C46 8808508. E-mail address: [email protected].
cases of cholera and 23,800 deaths occurred within 1 month.5 Most international travellers have the opportunity to be careful concerning food and water, but there is still a risk to catch cholera. However, the so called ‘back-packer tourists’, aid workers and people visiting friends and relatives are considered to be at greater risk than ordinary tourists for infection by cholera. Only a few cases of Cholera are imported to the European countries, with the exception of the UK (England and Wales), where an average of slightly more than 30 cases/year have been reported (17–48 cases/year 1995–2003).6 However, only a minority of them were for various reasons verified at the ESYV Reference Unit, Health Protection Agency, Colindale Avenue, London.7 (T. Cheasty, personal communication, 2004). Most UK cases are from the Indian subcontinent. Only 5–10% of cholera-infected persons do have the classical cholera gravis symptoms, but for these individuals there could be at risk of very severe disease. Previously healthy persons have developed in a few hours life-threatening symptoms. In 2003 a traveller died of cholera in Platte County, Nebraska just upon arrival.8 In 2004, a non-vaccinated 40-year-old Swedish male traveller fell ill during air-travel with severe watery diarrhoea, and was in hypovolemic shock with renal failure when he arrived to the airport.
1477-8939/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2004.10.001
162 However, his life could be saved due to prompt intensive medical care.9,10 Similar cases have been reported from Germany, where three men fell ill with severe watery diarrhoea, hypovolemic shock, and renal failure during a visit to a well known resort in Kenya, and a fourth man fell ill after returning home.11 In June of this year, a woman travelling from India to Europe fell ill on the air-flight between London and Brussels, and was taken to hospital with hypo-volemic shock upon arrival to the airport.12 There have been reports of travellers who have acquired cholera at popular holiday destinations as Phuket island in Thailand.13,14 However, 90–95% of the cholera cases are associated with mild symptoms or no symptoms at all. A number of patients with travellers’ diarrhoea could therefore be cases of mild cholera. The high numbers of imported cholera cases reported from Japan could be attributed to the intensive surveillance performed in that country.15,16 The good quality of the water and sewage system in the western counties will probably protected from spread of cholera from asymptomatic carriers, as long as these systems works properly. However, Dr Markku Kuusi of the National Public Health Institute in Finland, lists a numbers of waterborne outbreaks of different micro-organisms both in his own countries as in other Nordic Countries, England, Wales and the United States, due to failure of the water systems.17 Had the water sources been contaminated with cholera, instead of other bacteria as, e.g. Campylobacter, the result could have been disastrous. A greater risk for spread of cholera from asymptomatic carriers is food-handlers, and a number of such events are described in the literature.18–23 Since April 2004, an oral cholera vaccine (Dukoral) in approved in the countries of the European Union. This vaccine had been marked in Sweden since 1991. It has been tested in field trials in Bangladesh. The protection efficacy of the vaccine in the overall population was 85% for the initial 6 months of follow-up.24 Similar results were obtained in a study conducted among military recruits in Peru during the cholera epidemic.25 It is my opinion that we are morally obliged not to miss the opportunity to add vaccine protection to the important hygienic advice that we give to travellers. Author disclosure. Dr Per Arne Parment, is partner of a medical consultation firm, which has had assignments for SBL Vaccines and Solvay Pharmaceuticals.
P.A. Parment
References 1. Barua D. The global epidemiology of cholera in the recent years. Proc R Soc Med 1972;65:423–8. 2. Ramamurthy T, Garg S, Sharma R, et al. Emergence of novel strain of Vibrio cholerae O139 synonym Bengal. Lancet 1993; 342:387–90. 3. WHO. Cholera, 2003. Weekly Epidemiol Record 2004;79: 281–8. 4. WHO. Cholera vaccines. WHO position paper. Weekly Epidemiol Record 2001;76:117–24. 5. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire in July 1994? Lancet 1995;345:339–45. 6. www.hpa.org.uk/infections/topics_az/noids/annualtab. htm. Accessed 21september 2004. 7. www.hpa.orguk/infections/topics_az/cholera/menu.htm. Accessed 21 September 2004. 8. ProMED-mail USA (Cholera imported); 2003. 13. 20031007.2513 http://www.promedmail.org. Accessed 6 October 2004. 9. Hjertqvist M. Indienresena ¨r insjuknade i kolera. EPI-aktuellt 2004;3(16):2004. 10. Insulander M, Svenungsson B. Kolera efter Indienvistelse. Informationsbladet, Smittskyddsenheten, Stockholms la ¨ns landsting No 2; 2004. p. 3. 11. Kiehl W. Cases of cholera imported to Germany from Kenya. Eurosurveillance Weekly 1998;2(6). 12. ProMED-mail. An imported case of cholera in Brussels. ProMED-mail; 2004. 14.20040628.1726 http://www.promedmail.org. Accessed 6 October 2004 13. Anonymus. Man returns from Thailand carrying cholera. The Japan Times online Aug 22, 2001. http://www.japantimes. co.jp. Accessed 6 October 2004 14. Anonymus. Fallbericht zu aus Thailand importierter Cholera in Hamburg. Robert Koch—Institut. Epidemiologisches Bulletin 2004;25:198–9. 15. Wittlinger F, et al. Risk of cholera among western and Japanese travelers. J Travel Med 1995;2:154–8. 16. Sanchez JL, Taylor DN. Cholera. Lancet 1997;349: 1825–30. 17. Kuusi M. Investigating outbreaks of waterborne gastroenteritis. Application of modern epidemiological and microbiological methods. Helsinki: National Public Health Institute; 2004. 18. Tilak VW, Bhalwar R, Ratti JS. Epidemiological study of an outbreak of cholera in Delhi cantonment. Ind J Public Health 1997;41:61–7. 19. Goh KT, Lam S, Kumarapathy S, Tan JL. A common source foodborne outbreak of cholera in Singapore. Int J Epidemiol 1984;13:210–5. 20. Singh J, Bora D, Sharma RS, Khanna KK, Verghese T. Epidemiology of cholera in Delhi—1992. J Trop Pediatr 1995;41:139–42. 21. Swaddiwudhipong W, Akarasewi P, Chayaniyayodhin T, Kunasol P, Foy HM. A cholera outbreak associated with eating uncooked pork in Thailand. J Diarrhoeal Dis Res 1990; 8:94–6. 22. Savel’ev VN, Beliaev EN, Monisov AA, Kiuregian AA, Grizhebovskii GM. The cholera outbreak in one of the central regions of Dagestan [Article in Russian]. Zh Mikrobiol Epidemiol Immunobiol 1995;(Suppl. 2):52–6.
Cholera should be considered as a risk for travellers returning to industrialized countries 23. Lasch EE, Abed Y, Marcus O, Shbeir M, El Alem AA, Ali Hassan N. Cholera in Gaza in 1981: epidemiological characteristics of an outbreak. Trans R Soc Trop Med Hyg 1984;78:554–7.
163
24. Clemens JD, et al. Field trial of cholera vaccines in Bangladesh. Lancet 1986;2:124–7. 25. Sanchez JL, et al. Protective efficacy of oral wholecell/recombinant-B-subunit cholera vaccine in Peruvian military recruits. Lancet 1994;344:1273–6.