EPIDEMIOLOGIA: coleramandell2015

Clinical descriptions of cholera-like illness exist in ancient Sanskrit texts, and cholera has likely
been endemic to the Ganges delta regions for centuries, if not longer. Seven cholera pandemics
have been recorded since 1817. All of the pandemics are thought to have originated in Asia,
particularly from the Indian subcontinent. The El Tor O1 V. cholerae strain causing the ongoing
seventh pandemic is evolving. Polymorphisms in the genome of the pandemic strain have been
reported to have arisen in the Bay of Bengal and then to have independently spread to other
continents.25 All seven pandemics were likely caused by V. cholerae O1, but in 1992, V. cholerae
O139 emerged in India and Bangladesh to become the first non-O1 serogroup to give rise to
epidemic cholera. Although V. cholerae O139 initially caused large cholera outbreaks, at present,
this serogroup only causes a small fraction of cholera cases in Asia; furthermore, V. cholerae
O139 has not spread outside of Asia. Horizontal gene exchange appears to explain the molecular
origins of V. cholerae O139; the genome of this novel V. cholerae serogroup is essentially
identical to that of El Tor O1 V. cholerae, except that the genes encoding O1 antigen biosynthesis
have been replaced by genes encoding the O139 O-antigen. 26
Cholera had been absent from the Americas for nearly a century until 1991, when a large
outbreak began in Peru and rapidly spread throughout much of South and Central America.
During the ensuing decade, more than one million cases were reported. The source of the El Tor
O1 strain that gave rise to this epidemic is not certain; it has been proposed that contaminated
ship ballast water was the source, but this idea has been questioned. 27 Cholera did not reach the
Caribbean during this outbreak. However, in October 2010, a severe cholera epidemic began in
Haiti on the Caribbean island of Hispaniola, just 10 months after a devastating earthquake had
compromised that nations already tenuous infrastructures for sanitation and water. In the 2
years after the onset of the epidemic, more than 600,000 cases and 7400 deaths were recorded
in Haiti, and at least 6.1% of the population had been infected (Fig. 216-1). 28 In Hispaniola,
cholera spread from Haiti to the Dominican Republic, and from Hispaniola to Cuba, and imported
cholera cases from Hispaniola have been reported in several countries, including the United
States.29 Several lines of evidence indicate that cholera may have been introduced to Haiti by
United Nations security forces from Nepal, 30,31,32 suggesting that asymptomatic carriers of V.
cholerae can play an important role in transmitting cholera over long distances.
In 2011, there were approximately 600,000 cases of cholera and nearly 8000 cholera-related
deaths reported to the World Health Organization (WHO) from 58 countries (Fig. 216-2).33 These
estimates of cholera morbidity and mortality significantly underrepresent the true burden of this
disease because many cases are not diagnosed or reported. Recent estimates suggest that
approximately three to five million cholera cases occur annually worldwide, with 100,000
deaths.34 In the decade preceding the outbreak in Haiti, more than 90% of reported cholera cases
were reported from Africa, although the burden of disease in Asia is significantly underreported.