Final Draft

December 17, 2006

Historical Analysis of Cholera in Latin America

By Ivan J. Ramirez

Department of Geography, Michigan State University

Epidemiology 805

Dr. Michael Rip

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I. Introduction In 1991 the seventh pandemic of cholera reached the shores of Peru. This would

mark the reemergence of the disease in Latin America for the first time in the 20th

century (CDC, 1991). Outbreaks would follow in neighboring countries like

Ecuador and Colombia, and by the year’s end 15 countries in the region

including the U.S. would be afflicted. Although the fatality rate (<1%) of cholera

was dramatically less so than in the past, its morbidity remained high. Almost

400,000 cases were reported in 1991 of which 80% was in Peru (PAHO, 1996).

Since then, more than 1.2 million cases have been documented in Latin America

(PAHO, 2004). The scourge returned to the western hemisphere.

The outbreak was attributed to an Asian ship that docked in several ports

throughout the coast of Peru. It is hypothesized that the waste of infected

passengers was dumped into the sea and contaminated shellfish and the waters.

Contamination was possible because of Peru’s inadequate water and sanitation

services, which were in decline (PAHO, 1998). Another theory which has recently

gained support is one where multiple pathways via marine life that host the

cholera bacteria contributed to the outbreak. Furthermore, it is posited that these

bacteria and its host populations were increased and spread through climatic and

environmental mechanisms (Huq et al., 2001; Lipp et al., 2002; Rode et al.,

2002; Pascual et al., 2002; Pascual et al., 2000; Seas et al., 2000). While

these studies are not yet conclusive, they have spurred interest among the

climate science, public health, geography and many other disciplines.

How did cholera breach South American borders and regain a foothold in the

western hemisphere? Why after so many years? What is the history of cholera in

Latin America? Most historical accounts provide extensive details of epidemics in

Asia and Europe. A historical synthesis of Latin American accounts of epidemics

is lacking, at least from authors in the Northern Hemisphere (Politzer, 1959; De,

1961; Barua & Greenough, 1992; Hays, 2005; Ackerrnecht, 1965).

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Understanding the past may help us to shed some light on the present and

future.

The paper attempts to historically synthesize cholera epidemics in Latin America

from as far back as the 17th century to the present status. I describe the series of

epidemics in Latin America within the context of the global pandemics and refer

to them as ‘waves’. It also attempts to provide some insight to how the

understanding of cholera may have affected epidemics in Latin American

countries. Of course, this will be provided when data or reports are available. Did

Snow and Koch’s discoveries diffuse to these states? How have recent

discoveries of cholera ecology changed our perception of transmission in the

region? Following this introduction I present some background on cholera. I

describe the disease, the causative agent of cholera, transmission, prevention,

treatment and describe some historical context of discoveries in relation to each

topic. The next section briefly describes the history of the term cholera and the

pandemics. It excludes Latin American epidemics since I will be describing them

in the next section. The fourth section discusses the ‘waves’ of cholera epidemics

as they occurred overtime in Latin America and the reemergence of cholera in

1991. The final section is conclusions.

II. Cholera Background

Cholera is a diarrheal disease caused by the bacterium Vibrio cholerae, which

infects the small intestine of humans (Rabbini & Greenough III, 2001; WHO,

2000; De, 1961). In 1953, De discovered that vibrios release toxins within one to

five days, which sets off the course of the disease (Barua, 1992; WHO, 2000). It

typically proceeds in several stages, and begins with acute watery diarrhea and

vomiting that becomes continuous, and can lead to severe dehydration, uraemia,

and eventually death (WHO, 2000; De, 1961). By the mid-stage cholera victims

experience a rapid fall in blood pressure and radial pulse disappears; the eyes

shrink in and the skin becomes clammy and wrinkled (De, 1961). The disease

can spread without notice because the bacterium can be present for up to 14

days before any symptoms arise (WHO, 2000).

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Snow’s seminal work in London in 1854 had found that cholera was a water-

borne disease, but the agent or mechanism for transmission was not yet

understood (Huq et al., 2001, Vinten-Johansen et al., 2003). Although the

causative agent or mechanism was not yet known, it was beneficial for public

health. This finding led to many sanitary initiatives to prevent cholera. That same

year in December of 1854, a Florentine microscoptist named Pacini would

discover that agent, but could not demonstrate convincingly its etiology (Barua,

1992; Vinten-Johansen et al., 2003). Moreover, he published the findings in a

small journal during a time when contagion of cholera was being disputed (Lipp

et al., 2002; Barua, 1992). In 1883 Koch discovered the causative agent while

examining cholera in Egypt and India. He named it Vibrios cholerae (Barua,

1992; Lipp et al., 2002). Cholera could now be identified microbiologically.

Approximately 200 types of the Vibrio cholerae have been identified, but so far

two been associated with epidemics. The serogroup 01 is associated with

pandemics one through seven, and 0139, which emerged in 1992 in Bangladesh,

is believed to be the beginning of the eighth pandemic. This was the first time two

groups were present during global cholera outbreaks. Serogroup 0139 appears

to be a mutation of the 01 group and a non-01 group (as cited in Lipp et al.,

2002; Huq et al., 2001). Serogroup 01 consists of two biotypes: classical and El

Tor. The latter type was isolated from dead cholera victims in 1904 during

quarantine in Egypt. It is not clear why El Tor did not emerge as the primary

biotype until the seventh pandemic. But it was found in cholera epidemics in

Indonesia during the 1930s through forties (Barua, 1992). Cholera is normally transmitted through the ingestion of contaminated water, but

infection can also occur through the consumption of food such as seafood and

beverages (Glass & Black, 1992; Lipp et al., 2002). The vibrios are found in the

feces of humans, which are passed into water when evacuations take place.

There have also been studies which postulate that transmission may possibly

occur through flies (landing on infected species), fomites (inanimate objects), and

person-to-person (sweat). However these pathways are contentious and have

not been documented empirically (Glass & Black, 1992).

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In 1977 Colwell et al. found that humans were not the only reservoirs for the

cholera bacterium. Vibrios existed in natural marine and estuarine environments

such as those coastal inlands of Bangladesh (as cited in Lipp et al., 2002; Huq

et al., 2001; WHO, 2000). They attach themselves to phytoplankton, which are

eaten by zooplankton and crustaceans (shrimp and lobster). This finding could

possibly explain many sporadic outbreaks and those which emerged in “virgin”

environments such as Peru. Furthermore, it illustrated that solely poor hygiene

and cultural behaviors were not responsible for risk exposure (Huq et al., 2001).

Prevention methods could now look for vibrios in the environment and in the

laboratory specimens from humans (Huq et al., 2001; Barua & Greenough III,

1992).

This environmental aspect of the vibrio is actively being researched, particularly

in the context of a warmer world. Marine reservoirs are sensitive to changes in

the environment such as seas surface temperatures (Huq et al., 1992; Lipp et

al., 2002). So then what would be the implications if temperatures increased?

They are also sensitive to salinity. The right combination of factors may create a

habitat where the reservoir populations are able to thrive, and hence, vibrios may

increase. This hypothesis is being investigated and has been put forth to partially

explain the emergence in Peru (Lipp et al., 2002; Hug et al., 2001). I will

elaborate on this further when I discuss the Fifth wave of epidemics in Latin

America.

Adequate water and sanitation systems are the best methods to prevent cholera

and other diarrheal disease outbreaks. This means a safe mechanism for the

disposal of human feces and treatment of polluted water so it does not

contaminate the water supply. Public education is also important such as

informing of hygienic practices especially during times of outbreaks (WHO,

2000). Another prevention tip to avoid using waste water for irrigation. This can

infect crops and increase risk exposure (Barua, 1992). However, if water supply

is scarce and sanitation systems are inadequate, behaving appropriately will be

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difficult and in some cases not possible. How can you boil water or wash your

hands when there is no water to boil? Or avoid seafood when it is the cheapest

food available? These factors were largely attributed to the widespread

outbreaks in Latin America (Tickner & Gouveia-Vigeant, 2005; Witt & Reiff, 1991).

Lastly it is important to correctly identify cases of cholera and identify an

outbreak, and therefore surveillance is necessary and technology to clinically id

the disease. It was argued that in many cases in the Latin American countries,

cholera was not clinically identified (Barua, 1992). Therefore in some places the

number of cases may have been over reported and in others there may have

been less. However PAHO does report that generally in Latin America,

underreporting of cholera is approximately 50% (PAHO, 2004). I understand this

to mean that the cholera outbreak in 1991 may have been worse than statistics

illustrate.

There are several treatment methods that include oral rehydration therapy (ORT)

composed of a solution of salts and glucose, antibiotics, intravenous fluids, and

vaccines. ORTS have been the most effective in terms of cost and recovery.

According to the WHO (2000), this method can sufficiently treat up to almost 90%

of cholera victims unless the conditions are severe (lost too many fluids). In such

cases, a combination of ORT with intravenous fluids may help. Although

antibiotics are available, increasing resistance to them has been documented. If

effective they help to minimize the amount of fluids evacuated (WHO, 2000).

Vaccines are also available but they may create false security. Protection can

last up to several months. However its effectiveness requires more research.

III. History of Cholera The Term The scourge of cholera can be traced as far back as 500 – 400 B.C. in India,

where it is thought to have originated. There it was known as visuchika meaning

a disturbance of the stomach (Barua, 1992: 1). The word “cholera” is believed to

have originated from the Greek words chole (bile) and reins (flow) and first used

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by the Greek philosopher Hippocrates (470 – 377 B.C.). He described it as a flow

of bile (De, 1961: 4) and attributed cholera and all diseases to an imbalance of

humors (fluids) within the body (Thagard, 1996). Asclepiads, a follower of

Hippocrates, thought cholera as a flow of humor rather than bile (De, 1961: 4). In

Ancient China, it was called fok lun and was described as “something huddled up

in a confused manner inside the body…expressed by vomiting and purging.”

(quoted in Barua, 1992: 2). The present Chinese term is huo lon, which means

gastrointestinal infections (Barua, 1992: 2). In Latin writings around the third and

fourth centuries, cholera was referred to as “bitter”, a violent anger (De, 1961: 4)

It was known in Tibetan writings around A.D. 802 as nja, something which afflicts

the body and empties it of water (cited in Politzer, 1959: 11). Haida meaning

shattered was the word for cholera in Arabic around 900 A.D. and in Bengal it

was called olautha, purging and vomiting (Barua, 1992: 4). In the middle of the

17th century, Thomas Sydeham, the father of English Medicine, introduced the

term cholera morbus to distinguish it from anger (Barua, 1992).

The various terms found across cultures overtime have made it quite difficult for

researchers to accurately understand the history of cholera (Barua, 1992). Were

these recorded accounts of cholera as we currently know it or just severe

gastrointestinal infections? Each place or region described it as they observed

and experienced it. It was also difficult because sporadic forms of the disease

were being documented and the understanding throughout time changed; until

Koch’s discovery, cholera had been attributed to the environment or atmosphere

(as cited in Barua, 1992: 6).

Pandemics Although cholera outbreaks were recorded in India during the 14th and 15th

centuries, it wasn’t until the 16th century that widely documented accounts began

appearing. Portuguese settlers in Goa reported cholera epidemics with high

mortalities in the springtime of 1503 and 1543. Outbreaks in this same region

were also documented by the Dutch, French, and British (as cited in Politzer,

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1959: 12-13). Throughout Europe several reports of cholera epidemics were

found in places like London (1667 and 1669) Montpellier (1649), Nuremberg

(1689), Ghent (1665), Nimes (1654), and Vienna (1768). There were even

reports of outbreaks as far away as Brazil (1658) (as cited in Barua, 1992: 4-5;

Dubos, 1976).

It was not until the 19th century that the first pandemic (1817-1829) would take

course. According to Politzer, the year 1817 appeared to be a turning point in the

virulence of cholera. The spread of cholera became quick and severe covering

almost 200,000 square miles in three months across India (as quoted in

Politzer, 1959: 18). Interestingly it was also a year of heavy rains, floods, and

crop failures. Cholera found its way by land and sea to Southeast Asian countries

including Nepal (1818), Ceylon (1818), Burma (1819), and Siam (1820), which

was reportedly devastated (as cited in Barua, 1992: 8; Politzer, 1959: 19). By

1821, it reached the shores of Oman and was likely imported by Indian

expeditionary troops from Bombay. China was invaded by land in 1817 and by

sea in 1820. Outbreaks would last until 1824 and follow the caravan route along

the Great Wall. In the Persian Gulf and Mediterranean (1821), cholera would

affect the ongoing war between Persia and Turkey. In less than three weeks,

more than 15,000 people were killed in the port city of Basra in Persia. It reached

Russian shores via the Caspian Sea in 1823, but was not so severe due to

severe winter conditions. It is suspected that these infections were recrudescent

(as cited in Barua, 1992: 8; Politzer, 1959: 19-20). Japan (1822) would be

invaded via the sea from Java and Mauritius (1819) via Ceylon (Barua, 1992: 8).

By the second pandemic (1829-1851) cholera would reach the New World. It

would arrive in the summer of 1832 via infected Irish immigrants in Quebec and

the east coast cities of New York and Philadelphia. Quarantine measures were

implemented but not all incoming ships could be inspected. It made its way

through to the south and New Orleans, where several importations and

exportations of cholera and other infectious diseases were reported. “Mass

burials were held” and outbreaks continued until 1835 and resurged in 1848. In

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South America, Peru and Chile were the first countries to be afflicted. It would

later spread to the Caribbean and Central America. Spain, Portugal, and

Morocco reported outbreaks from 1833 – 1834. A ship from England was

responsible for the Iberian epidemics (Barau, 1992). England itself had

experienced its first outbreak during this pandemic in 1830 and cholera

“seemingly took advantage of the new conditions of industrialized England—

entering through the seaports…new highways and railroads, and attacking first

the most densely populated and…the desperately poor” (Winton-Johansen et

al., 2003: 170). Sweden, Denmark (1850), Southern France and parts of Central

Europe experienced cholera outbreaks and for some it was the first time. Cholera

would subside from 1839 until 1846 in Europe and then reemerge. Researchers

are not sure whether these outbreaks in Europe were recrudescent or

importations. The same questions arose during a major outbreak at a Mecca

pilgrimage in 1835. China (1835) would again be afflicted and cholera was again

found in the Mediterranean (1835-1837), northern Africa (1835, 1850), and now

in Sudan and Ethiopia (Barua & Greenough, 1992; Politzer).

Figure 1. Map of Pandemics from 1832 to 1873

Source: http://www.nsf.gov/news/speeches/colwell/rc01_anatlesson/sld018.htm

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At this time, it was still believed that cholera was attributable to miasma. The fear

of cholera and the spread via unhygienic behavior was so prevalent that a

national conference on sanitary measures was held in Paris in 1851 and would

meeting many times until 1938 (Barua, 1992).

The next four pandemics would strike many new places for the first time (i.e.

Southern cone in South America) and many old places continuously. Pilgrimages

in Mecca reported several outbreaks in 1865, 1881, and 1902. The 1865 would

claim one-third of the visitors. In 1866, some of the worst epidemics were

experienced throughout Western Europe in countries such as Austria, Hungary,

and Germany. It was likely exacerbated by an ongoing war in the region (Barua,

1992). That same year in New York City, it is believed that the first public health

board was created in direct response to cholera (as cited in Huq et al., 2001).

Snow’s discovery of the water connection would strongly influence public health

measures. However, bad air and filth was still blamed for the cause of cholera.

By the sixth pandemic which began in 1899, bacteriology was at work. Koch had

found the causative organism of cholera. However many cases and outbreaks

would continue in many parts of the world. In Leningrad about 800,000 lives were

lost to cholera from 1893-94. Cholera was no longer present in Latin America

after the 1890s and would not see the disease until the seventh pandemic

reached its shores in 1991 (Barua, 1992).

The seventh pandemic is illustrated in Figure 2 (below). Until that time, the

classical biotype of cholera was responsible for the pandemics. Furthermore,

cholera was mainly confined to Asian countries. In 1961, cholera spread out of

Asia and again cholera would return to Africa, the Mediterranean, Soviet Union,

the Middle East, and eventually the western hemisphere. The number of cases

would spike in 1971; the largest number of cases ever reported in that pandemic

occurred that year of which Bangladesh claimed one-third. Until that time El Tor

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was now the dominant biotype of cholera. A growing world population along with

new transportation systems would enable for rapid and wide spread. It was

anticipated by many that cholera would surely strike Latin America in the 1970s

and 80s, but somehow its arrival would stall until a decade or two later. (Barua,

1992).

Figure 2. Map of Seventh Pandemic

IV. Epidemic Waves in Latin America This section describes the series of cholera epidemics or “waves”, which

occurred throughout Latin America since the first pandemic. (See Figures 3 & 4

for a mapping of epidemics in Latin America).

First and Second Waves (1832 – 1859)

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________________________________________________________________ The colored dots represent epidemics in each respective country. Please note they do not refer to the specific location of the epidemic. Please refer to the bibliography section for sources. Map by Ivan Ramirez.

The First Wave (1832-1851) of cholera began not long after the independence of

many South American countries and during the second pandemic (1829-1851).

The Second Wave (1853-1859) would take place during the third pandemic

(1852-1859) and Snow’s discovery (1854).

In 1832 Peru and Chile were the first to encounter cholera in the Latin American

region. These first two accounts have been contested and the pathways in which

they arrived were not clear, but they have been cited in many literatures (Barua,

1992; Politzer, 1959; Hays, 2005). The cholera accounts in the Caribbean are

well documented.

In February or March of 1833, Cuba would experience its first of several

outbreaks (Politzer, 1959: 24; Kipple, 1985). The disease apparently came via

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Spain and the U.S. The consequences would be severe and by September of

that year, more than 22,000 Cubans would be dead (Kipple. 1985). According to

Kipple (1985), cholera “raged in white-hot fashion” and overwhelmed Havana’s

two cemeteries. He also notes that blacks (free and slaves) were affected the

most and died at three times the rates of whites. At the time, Cuba under Spain’s

rule harbored a large population of slaves. It was also found in the poorest

sections of cities like El Barrio of San Lazaro in Havana, where sanitation was

significantly inadequate. Again in 1850, cholera would resurge in Havana even

though stringent quarantine measures were taken. From 1850 to 1854,

approximately 32,000 cases were reported with a case fatality rate of 53%

(Kipple, 1985).

Cholera would visit the island of Jamaica for the first time in 1850. According

reports in Kingston, it created a “terrible rate of mortality…such that husbands

refused to lift dead wives into their coffins and mothers deserted their children”

(cited in Kipple, 1985). This was not uncommon as was evident in Brazil, which

I will describe later, and more recently in the 1992-93 outbreak in the Delta

Amacuro in Venezuela. The disease would subside in Jamaica by 1852, but

close to 30,000 deaths were documented and in some reports it closer to 50,000.

Puerto Ricans were anxious during this time, and averted invasion through strict

quarantines of ships until 1855. A weary public resorted to church and faith for

support. According to Kipple, churches were overwhelmed and a “marathon” of

prayers were hoped would appease God’s wrath on the people (1985). Finally in

the fall of 1855, the first cases were reported in the eastern city of Naguabo,

apparently “sneaking in” from St. Thomas. Draconian measures of cordon

sanitaire were implemented including the disinfection of incoming mail with

vinegar. There were even measures to scatter the bad air by “firing guns on the

heavens”. In the end, almost 25,000 were recorded (Kipple, 1985).

Snow’s discovery in 1854 had not yet influenced authorities in the Caribbean to

act—in time— based on this new knowledge of water transmission. However, the

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events did prompt them to take some preventive measures, mostly in the form of

sanitary improvements, for future epidemics (Kipple, 1985).

Accounts of outbreaks in Mexico’s coasts and higher plateaus were widely

documented. In some accounts cholera arrived in the spring of 1833 and others

believed it was in 1834 (cited in Politzer, 1959; Guzman et al., 1999).

According to Guzman, 14,000 lives were lost from August to November of that

year. Cholera would return in 1848, 1850 (via trade from Europe and New

orleans), and from 1853-1854 (as cited in Politzer, 1959; Guzman et al., 1999;

Barua, 1992).

In Central America, Nicaragua and Guatemala were struck in 1837. Reportedly

the former’s outbreak was more severe (Politzer, 1959: 24). Cholera would not

reach Panama until 1849 via a ship from New Orleans en route to the Chagres

River. Epidemics were also documented in various parts of the Central America

in 1856 (Barua, 1992).

Outbreaks in South America’s Colombia and Ecuador were reported in the early

1850s; however, these accounts have been debated like those earlier in Peru.

According to Politzer an outbreak took place on the northernmost coast of

Colombia. Guyana experienced an outbreak in its coast in 1837 and 1857

(Politzer, 1959). In Venezuela, outbreaks were found in 1853-1854 and again in

1857 (Politzer, 1959; Barua, 1992; Colmenares, 2002).

Cholera invaded Brazil in 1853 and remained until 1856. This account was well

documented in a study by Cooper (1986). In the 1855-56 epidemic, Belem was

the first city to encounter the disease. Located at the mouth of the Amazon River

in the North, it was an entry/exit point for trade. Apparently cholera came in the

infected bowels of sailors and passengers. It soon spread to 13 provinces and

afflicted the worst on the populations in Northeast Brazil. In the Bahia province,

almost 36,000 people had died. According to the British Consul in Belem, 4% of

the population in that town had perished; these were mostly Blacks and Indians.

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Samuel Vines of the Consul reports: “the sick were abandoned, and the dead

went unburied…entire crews of canoes were carried off and small villages were

depopulated” (as cited in Cooper, 1986). Dr Santa Rosa of Belem diagnosed

the first cases of cholera. He documented the classic symptoms of sunken eyes,

severe diarrhea and vomiting. His recommendations for a strict quarantine were

ignored; and in fact he was told he was wrong in his analysis. Such measures

would have been detrimental to trade and Brazil’s economy. Furthermore, the

medical commission, mostly comprised of anti-contagionists, believed what was

occurring in Belem was a local phenomenon and could not have possibly been

transmitted from person-to-person. In Rio de Janeiro, the same thought persisted

and it was believed to have been a malady due to “overindulgence in food, drink,

or…sex”. However, the rapid spread to neighboring and far away towns could not

be explained considering that atmospheric conditions had not been any different

from those in the past. A Dr. Rego from the Central Board of Public Health notes

“it seems that reason is on the side of the advocates of importation” (as cited

and quoted in Cooper, 1986). By 1856, Cholera had taken almost 200,000

lives.

Third and Fourth Waves (1861 – 1895)

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________________________________________________________________

________ Figure 4. The colored dots represent epidemics in each respective country. Please note they do not refer to the specific location of the epidemic. Please refer to the bibliography section for sources. Map by Ivan Ramirez. The earliest reports of epidemics within the Third Wave were in Brazil’s

Northeast from 1861-1863. From 1865 to 1870, there would be several

outbreaks, some of which were attributed to the “Great War” between Paraguay,

Argentina, and Brazil and neighboring countries (as cited in Cooper, 1986;

Guzman et al., ). In April of 1867, Rio de Janiero and Rio Grande do Sul

reported the first cases, apparently imported via Paraguay. Another outbreak

would occur again in 1868 (Politzer, 1959: 36). In Argentina, cholera would

arrive in Corrientes, a northern city near Paraguay in 1866, then Buenos Aires in

1867, and interior provinces in the west in 1868. According to Politzer this

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allowed entry to Peru and Bolivia. Outbreaks in Uruguay via the Parana River

were reported in 1868 (Politzer, 1959: 36).

Caribbean accounts were found in Cuba and now the Dominican Republic.

Cholera would return to Havana in October of 1867. Again Black slaves were

affected the most and it was believed that they were racially susceptible to the

disease. Although the amount of cases (~ 8,000) from 1867-68 was considerably

lower than past epidemics, the case fatality remained high at 85% in 1867 and

50% in 1868. Snow’s discovery as mentioned earlier, had prompted officials to

improve sanitation and this was believed to reduce the morbidity on the island

(Kipple, 1985). In the Dominican Republic, an outbreak took place in 1866

(Politzer, 1959: 32).

In Central America (1866-1868), there were reports of outbreaks in Nicaragua

and the British Honduras via ships from New Orleans (Politzer, 1959: 36).

The Fourth Wave (1880-1895) would strike South America in 1886 and makes its

last impression in that century in 1895. Argentina and Chile were invaded from

1886 to 1888. Uruguay in 1895 and Argentina its last cholera outbreak in 1894-

1895 (Politzer, 1959: 39). Brazil reported its final outbreaks in 1893-1895.

According to Stepan (1981), several outbreaks were reported at the Hotel of

Immigrants in the summer of 1893. It likely imported and thrived due to poor

water sanitation conditions. Dr. Alfredo Lutz investigated and confirmed the

diagnosis of cholera through bacteriological analysis in several instances at that

same location. However there was much resistance from the medical community

in Brazil, the same resistance that Dr. Rosa experienced in 1855. Many believed

the “cases were only diarrhea” and denied the existence of cholera in Brazil. Lutz

effectively proved his case by disproving an alleged cholera outbreak, where

2,000 people became sick; this time is was simply food poisoning. Although

Koch’s discovery of the cholera bacterium was now known, the Brazilian

authorities may have found the disease threatening to its.

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Fifth Wave: Reemergence in Peru (1990 – Present) In October of 1990 on the northern coast of Peru, cholera would resurface for the

first time in the twentieth century in Latin America (PAHO, 2003). The Fifth Wave

had begun and cholera moved rapidly through its neighboring countries. (See

Figure 5 for the initial outbreak trail in South America). It affected most of

South America, Central America, and reached the U.S. The widely accepted date

of the outbreak is in late January of 1991 in the coastal city of Chimbote. Latin

America would now face the El Tor biotype and participate in the Seventh

Pandemic (as cited in Huq et al., 2001).

By March of 1991, cholera had reached Ecuador and Colombia. In April it was in

Brazil. By the summer, Mexico, Guatemala, Bolivia, Honduras, Panama, and

Nicaragua reported outbreaks (Guzman, ). At the end of 1991, 391,724 cases

across 14 countries were reported in Latin America (Geography Department,

University of Colorado at Boulder, 2001). Although the case fatality rate of 1%

was considerably low, the morbidity remained high.

Figure 5. Map of Initial outbreaks in Latin America

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Many believe it was imported via the waste of infected passengers from an Asian

ship that docked along the coast of Peru. However multiple outbreaks were

reported in several places within Peru and outside of Peru where importation

could not be explained. A case of multiple pathways that consist of social and

environmental factors has gained much support. Specifically the climate

variability patter known as El Nino and global change were attributed to the

spread in the western hemisphere (Patz, 2002; Seas et al., 2000; Pacual et al.,

2000;2002).

Figure 6.

________________________________________________________________ Figure 6. This graph shows the number of cases in the Americas from the time of outbreak to 2002. Almost 1.2 million cases have been reported. This map does not include cases from Canada and the U.S. The map also shows the years that coincide with El Nino-Southern Oscillation indicated by the red circles. The largest spikes were in 1991 and 1998. A decline is seen from 91 until 1998, likely a result from preventive measures implemented.

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Certainly there seems to be some association with climate variability but El Ninos have occurred in the past and outbreaks did not take place. In places like Bangladesh where cholera is endemic, the relationship is much more evident. As Figure 7 shows, there are pronounced spikes in 1982-83, 1986-87, 1992-93, and 1997-98, all El Ninos years. During El Nino sea surface temperatures become anomalously warm and therefore it is a good indicator of its presence (Pascual et al., 2000).

________________________________________________________________ Figure 7. Conclusions Cholera had not struck in more than a hundred years in some places in Latin

America. In the past, the pathways were likely via importation through travel and

trade, and recrudescence. However, the analysis given here was limited to dates

and places, with few instances that indicated how the outbreaks began. The

current debate and ongoing investigations that explore environmental pathways

should consider reexamining outbreaks in the past in order to assess if any

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unexplained outbreaks may have relationships with anomalous sea

temperatures. Of course, these are only correlations, but they may prove useful

in early warning systems for cholera. This may be of crucial importance as sea

surface temperatures continue to warm. How will that affect the current pandemic

and future pandemics if any? Lastly it should not be ignored that social factors

are instrumental in the sustainability of outbreaks and possibly their initial

outbreaks as may have been evident in Peru and Latin America.

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