132 CHAPTER
Vibrio cholerae (Cholera) Attack
Nishanth S. Hiremath, Srihari Cattamanchi, Vidyalakshmi PR, and Milana Trounce
DESCRIPTION OF EVENT
Cholera is an acute diarrheal illness caused by the bacterium Vibrio
cholerae. If cholera is left untreated, it leads to dehydration and death.
V. cholerae is a Centers for Disease Control and Prevention (CDC) cat-
egory B bioterrorism agent. It is a motile, curved, gram-negative rod
that exists in nature independent of a mammalian host and is a normal
inhabitant of surface water. More than 99.9% of naturally occurring,
waterborne V. cholerae organisms are associated with tiny crustaceans:
zooplankton called copepods. The cholera bacteria attach themselves to
copepods and travel with their hosts as they follow their algae and
plankton food source. Attempts to limit cholera transmission have used
this fact and led to the active filtering of water through low-tech filters
(e.g., eight layers of “sari” cloth in Bangladesh).
Although cholera is virtually nonexistent in North America (0 to 5
cases per year), it is endemic in agrarian areas with poor sanitation,
crowding, famine, and war.1 Areas of occurrence include Sub-Saharan
Africa, the Middle East, South Asia, Southeast Asia, and South America.2
Figure 132-1 displays all countries that reported cholera outbreaks from
2010 to 2013.3
Approximately 3 to 5 million cases of cholera occur each year world-
wide, with more than 100,000 attributable deaths.4 During the nineteenth
century, the disease spread from the Ganges Delta region in India, the
original reservoir of the disease, across the world.4 Cholera first spread
as a pandemic in 1817; subsequently, six pandemics occurred that killed
millions of people across all continents.2 During the seventh pandemic
that began in 1961, the El Tor biotype of V. cholerae Serotype O1 orig-
inated in Sulawesi, Indonesia, and rapidly spread to other countries in
Asia, Europe, and Africa, reaching Latin America in 1991.4 V. cholerae
O139 Bengal, a new strain identified in India and Bangladesh, caused
an outbreak in 1992, which is still confined to Asian countries.2 The
recent Haiti cholera outbreak in October 2010 due to a strain found
in South Asia has produced by the date of this writing more than
6631 attributable deaths and 470,000 cases of cholera.5 The CDC has
declared the ongoing Haiti cholera outbreak as the worst outbreak in
recent history; it is also the best-documented outbreak in modern public
health.5
Transmission of cholera occurs via the fecal-oral route. Ingestion of the
typical environmental reservoir of V. cholerae, undercooked food, espe-
cially shellfish, and “burial ceremonies requiring the handling of intestinal
contents” have also been implicated in the transmission.6 Cholera can sur-
vive for 24 hours in sewage, about 6 weeks in water containing organic
matter, and 16 days in soil. V. cholerae can withstand freezing for 3 to
4 days but is readily killed by dry heat at 242.6 °F (117 °C) or by boiling.7
Of the 18 cholera investigations undertaken by the CDC between 1988 and
1998, four occurred in the United States and involved various factors
including patients at nursing homes, raw fish, food imported from other
726
countries, and contaminated food on an international flight.8 In addition
to sporadic cases, epidemics sometimes occur, including several during
the 1990s in South and Central America.8
Only two serotypes of V. cholerae cause epidemic disease: the O1
serotype (divided into two groups, El Tor and “classical”) and the
O139 serotype. Other serotypes cause sporadic cases of gastroenteritis.
Recently, the O139 serotype has spread from India and Asia to the
Middle East.9 At this time, there is no weaponized form of the disease.
A bioattack using V. cholerae would most likely occur via contaminated
water or food source.
Infection can occur after the ingestion of as few as 1000 organisms.
Infection is more likely in patients who are receiving acid suppression
therapy because gastric acid at a pH of less than 2.5 will effectively kill
V. cholerae organisms. After ingestion, the incubation period is 4 hours
to 5 days, with most patients presenting within 2 to 3 days.7,10,11 Most
V. cholerae infections are asymptomatic or present with only mild dis-
ease. Depending on the serotype, up to 75% of infected individuals will
remain asymptomatic. Of the other 25%, the majority have a mild diar-
rheal illness not requiring medical attention, 5% require hospitaliza-
tion, and 2% develop classic cholera (also known as cholera gravis)
with voluminous “rice water” stools. The symptoms of cholera gravis
include a gradual to sudden onset of vomiting, malaise, headache,
and intestinal cramping with mild or no fever, trailed by painless
and voluminous diarrhea that looks likes rice water. Fluid losses surpass
5 to 10 L/day and up to 1 L/h of diarrhea is not uncommon. Patients
with blood type O are more likely to develop severe disease. The mor-
tality rate in the 2% with cholera gravis is 50% to 75%, giving an overall
mortality in infected persons of 1% to 1.5%. Patients can die within 2 to
3 hours of the initial signs of infection, but death in the untreated indi-
vidual usually occurs after several days.12 The mortality risk is increased
in children (10 times greater than in adults), the elderly, and pregnant
women. There is also an amplified risk of fetal death.13
Definitive testing for V. cholerae is performed relatively easily in the
laboratory. Stool cultures should be sent and plated on thiosulfate-
citrate-bile salts-sucrose (TCBS) agar or tellurite, taurocholate, and gel-
atin agar (TTGA). Gram stains of stool may show sheets of curved
gram-negative rods. Other rapid diagnostic methods primarily used
in epidemiological studies include the detection of V. cholerae organ-
isms in stool specimens by polymerase chain reaction and monoclonal
antibody-based stool tests.14
The most likely scenario for an outbreak would involve a large num-
ber of otherwise healthy persons presenting over a period of several
days with severe diarrhea or gastroenteritis symptoms and dehydration.
Once a few cases of cholera are confirmed, the possibility of biological
terrorism should be considered.
Cholera should be included in the differential diagnosis of all cases
of severe watery diarrhea and vomiting, especially those producing