Vibrio cholerae

DR ARCHANA BHAT K
Cholera-Etiological agent
Vibrio cholerae→ either serotype O1 or serotype O139.

Other serotypes are known as V cholerae non-O1 non-

O139 → do not produce cholera toxin and therefore do not
cause true cholera;
Instead, these nontoxigenic serotypes cause a similar
diarrheal type of illness, which is more similar to a
gastroenteritis
 Group B -Antigenically
Group A-common H Ag
and Biochemically
(Cholera vibrios)
Heterogeneous
Biochemical similarities

Serogroups/serovar Based
on somatic O Ag All the isolates of epidemic cholera
belonged to serogroup O1
Other vibrio isolates which
are not agglutinated by the
O1 antiserum came to be
called Nonagglutinable
vibrios(NAG)
Hikojima There is no difference in
Currently upto 139 pathogenicity between
the three serotypes
They were considered
nonpathogenic (except
O139)
Serotypes of V.cholerae O1
Serotype O antigen types
Ogawa A,B
Inaba A,C
Hikojima A,B,C

•Ogawa - most common serotype isolated followed by Inaba

• During epidemics, shifting between serotypes can take place
• Hikojima - unstable transitional state, both Inaba and Ogawa
Ags expressed
Epidemiology
Countries with poor water and sewage treatment are likely
to be the victims of cholera.

This disease is very unlikely to be spread from person to

person.
Transmission
•Contaminated water
•Contaminated food

• Person to person transmission not

common(Hand contamination of
stored drinking water has been a mode of domestic spread)
• Fecal-oral transmission is possible
 Epidemiology of O1 and O139
➢ Serogroup O1 and O139 cause outbreaks.

➢ O139 was first identified in a massive outbreak in

Bangladesh in the year 1992, but as of now, it is only seen in
some sporadic cases .

➢ It has not been reported outside Asia.

 Epidemiology
✓Endemic in Ganges and Brahmaputra areas of West Bengal

✓ 1817 – 1923 ---- 6 pandemics by classical biotype

✓ 1966 ---- 7th Pandemic from Indonesia by El Tor biotype

7th pandemic differs:

▪Origin: Indonesia(Originated outside India)

▪El tor (all others-Classical)
▪Less severe/high carriage rate

▪Replacement of classical biotype by El tor

8th Pandemic ? Spread of 0-139
✓1992 ---- Small epidemic from Chennai by O 139 but
replaced by El Tor by 1994.
✓Several identify that onset of 0-139 is considered as
8th pandemic started in India.
✓Cholera in India – usually hot months between March to
May before monsoons.
✓Transmission through contaminated water source
O139 serogroup
-Since 1992 has caused several epidemics and outbreaks -
coastal India & Bangladesh.

™on O1/O139 serogroups - occasional sporadic outbreaks

N
of diarrhea & extraintestinal manifestations, but never
epidemic cholera
Clinical features
Site of infection – small intestine

Incubation period – few hours to 5 days (usually 2 – 3 days)

Dependent on inoculum size
Clinical features
❑In most cases→ symptoms range from mild to moderate

❑In 20% of cases→ severe life-threatening fatal conditions

appear.

❑The most severe manifestation of the disease, “cholera

gravis,” affects only minority of the patients infected with
CT-producing V. cholerae
❑Classical strains are more virulent than El Tor strains.

❑Begins with sudden profuse watery diarrhea.

❑Initially the stool will be dark brown with solid nature;
gradually it turns to inoffensive whitish watery stool giving a
rice water appearance.
❑The massive fluid loss via vomiting and excessive diarrhea
❑Causes dehydration and leads to shock and may be death
❑Mortality without treatment – 20 – 50%
Laboratory diagnosis
Specimen: Freshly passed stool/ Rectal swab in case
of children
Transport: Venkatraman – Ramakrishnan medium,
Cary – Blair medium
(Blotting paper dipped in stool sent in plastic
envelope)
Macroscopy: Rice water stools – Mucus flakes
Microscopy:
1. Unstained preparation:
- Hanging drop – Darting motility

2. Stained preparation:
- Dilute carbol fuchsin – Pink comma shaped bacilli
Laboratory diagnosis
Enrichment medium: Alkaline peptone water(pH 8.4) – after 6 hours
hanging drop to demonstrate darting motility, subcultured on Mac
Conkey agar
Direct plating:
- Mac Conkey agar/ Nutrient agar – Non selective medium
- TCBS (Thiosulphate citrate bile sucrose) Selective
medium
- MGTTA (Monsur’s gelatin tellurite taurocholate agar)
 Culture Media
TCBS agar:
-Thiosulfate, citrate, bile salts (as
inhibitor), sucrose
-pH of 8.6
-yellow colored colonies

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Laboratory diagnosis
Non lactose fermenting, Gram negative comma shaped bacilli,
oxidase positive, exhibiting darting motility
Organism is identified by biochemical reactions and the serotype
confirmed by agglutination with O 1 antisera – Vibrio cholerae O1
Serotype identified by,
Serotype Ogawa antisera Inaba antisera
Ogawa Agglutination positive Negative
Inaba Negative Agglutination positive
Hikojima Agglutination positive Agglutination positive
First the colony is tested with O1 antisera →

If found negative, then tested with O139 antisera

Laboratory diagnosis
Identification of Classical and El Tor biotypes
Reactions El Tor Classical
Hemolysis on Sheep Blood agar + -
Agglutination of Chick RBC + -
Vogues Proskauer + -
Polymyxin B 50 units R S
Group IV phage R S
Treatment of Cholera
F‰luid replacement: most important
-Mild to moderate fluid loss: oral rehydration solution (ORS)
-Severe cases: Intravenous fluid replacement with Ringer’s
lactate (or normal saline) → ORS
Antibiotics have a minor role as the pathogenesis is toxin
‰
mediated
Drug of choice: Macrolides (Erythromycin or Azithromycin)
-Alternatives - Doxycycline, tetracycline or ciprofloxacin
Prevention
General Measures
-Safe water, sanitary disposal of feces
-™
Proper food sanitation
-™
Notification
™
-™
Chemoprophylaxis - Tetracycline
- Household contacts, only during epidemics
 Vaccines

Currently there are three WHO pre-qualified oral cholera

vaccines (OCV): Dukoral®, Shanchol™, and Euvichol®.

All three vaccines require two doses for full protection

WHO recommends use of vaccine for epidemics and outbreaks

but not during inter epidemic period
Killed Whole-cell vaccine(Oral vaccines)

1. Whole-cell (WC) vaccine - (classical and El Tor, Inaba and

Ogawa)Shanchol

2. Whole-cell recombinant B subunit cholera vaccine

(WC/rBS) (Dukoral) – same WC vaccine + recombinant
cholera toxin B subunit
Shanchol
Shanchol™ and Euvichol® are essentially the same vaccine
produced by two different manufacturers.

Shanchol™(manufactured by Shantha Biotec in India)

They are given to all individuals over the age of one year
Dukoral®
❑Dukoral® is mainly used for travellers.
oTwo doses of Dukoral® provide protection against cholera
for 2 years.
oage >2 years.
▪Protection is short lived.
▪Children are better protected
▪Used during epidemics and outbreaks but not during inter
epidemic period
Live oral cholera
The FDA recently approved :Live attenuated
•Single-dose vaccine
•Use mutant strains lacking gene encoding cholera toxin
•Travellers
Vaxchora® has been reported to reduce the chance of severe
diarrhea in people by 90% at 10 days after vaccination and
by 80% at 3 months after vaccination.
Direct MicroscDirect Microscopyopy
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