Cholera in Haiti: No Respite from Unintended Consequences

Cholera is a disease caused by a tiny bacterium but fully aided and abetted by infrastructure and sanitary deficiencies. This disease which humans (including our 11th president James Polk who suffered a fatal case after leaving office) have battled for centuries, thanks to the steady march of civilization, has ceased to be a threat to many parts of the world. The US, for example, had just 7 cases of cholera reported in the US and all were travel-related. The fact that no secondary spread occurred is testament to the prowess of our sanitary systems. Though our sanitary engineers may have created a fortress which cholera can not penetrate, the rest of the world has not been so fortunate as millions of cases occur annually and approximately 100,000 individuals die at the hands of this ancient foe. 

No discussion of cholera can occur today without mentioning the plight of Haiti. This island nation had successfully dodged cholera during each of the prior 6 pandemics as well as for the ongoing 7th pandemic until 2010. In a tragic example of unintended consequences, the massive aid effort following the 2010 earthquake that brought people from all corners of the globe to Haiti also brought their pathogens, including cholera.

After much controversy it has been definitely established that the cholera outbreak in Haiti -- which has killed 10,000 and created ghost towns -- was delivered to Haiti in the feces of UN troops from Nepal whose defecation patterns seeded a river with the deadly bacterium. After 6 years, Haiti still suffers from cholera and, because of the devastation the earthquake wrought on this nation which had frail infrastructure to begin with, it is difficult to imagine how Haiti can be cholera free ever again. Indeed, the cholera elimination plan spans until 2022. Hurricane Matthew's influence, as detailed in the New York Times, can be expected to be a boon to cholera as feces laden with the bacteria are washed into drinking water supplies. This is another example of how an infectious disease emergency can threaten a nation's national security and accelerate failed state status.

I was in Haiti just after the earthquake and saw a sight of utter devastation where entire hillsides became public latrine, where simple sanitation was non-existent, where overcrowding was the norm--in short a playground for any pathogen. I myself was in the midst of a likely norovirus outbreak that tore through a US government forward operating base. 

There is hope, however, in the fact that cholera ceases to be a threat with the sterilizing effect of just a modicum of civilization not to mention cholera vaccination (a vaccine, manufactured by PaxVax, is now available in the US as well). 

Intestines in the Time of Cholera

The world has experienced 7 cholera pandemics since 1817. The first six were caused by the classic biotype of the O1 serogroup of Vibrio cholerae. The 7th pandemic which began in 1961 and is still ongoing (with spread to Haiti and Mexico) is due to the less virulent El Tor biotype of O1 V.cholerae.  In a project, my colleagues and I estimated global cholera costs as exceeding $3 billion annually. 

It was in 1849 during the 2nd pandemic that Dr. John Snow made his pathbreaking epidemiological discovery regarding the role of water in the spread of the cholera microbe--yet to be identified (see The Ghost Map and The Strange Case of the Broad Street Pump). During that pandemic, Dr. John Neill of Philadelphia preserved an intestine from a patient for further study.

The New England Journal of Medicine just published the results of a successful attempt to extract the cholera microbe from that over-a-century old specimen. 

The bacterium recovered was of the classical biotype (as predicted) and had a striking similarity to the reference strain of the classic biotype suggesting that little evolution has occurred since 1849 because of some selective pressure that is constraining its genome. 

Cholera is a fascinating disease--see its biography--and this study fills in a few chapters in its life with humans.