International Notes Cholera -- Peru, 1991

On January 29, 1991, the General Office of Epidemiology, Ministry of Health (MOH) in Lima, Peru, received reports of an increase in gastroenteritis in Chancay, a coastal district approximately 1 hours by road north of Lima (Figure 1). On January 30, teams from the Field Epidemiology Training Program (FETP), Division of Epidemiology, MOH, traveled to Chancay to investigate this problem.

Investigation identified an outbreak of diarrheal illness that had begun on January 23. Illness in initial cases was characterized by voluminous watery diarrhea, vomiting, and to a lesser extent, severe muscle cramping. Vibrio cholerae O1, Inaba, biotype El Tor, was isolated from patients' stools from Chancay and Chimbote by the National Institute of Health, MOH; Cayetano Heredia University; and the Navy Army Medical Research Institute Detachment and was confirmed by CDC. Additional cases of gastroenteritis have been reported from the cities of Chimbote, Piura, Trujillo, and Chiclayo along the northern coast of Peru (Figure 1).

Active surveillance and a national laboratory network have been implemented throughout the country. From January 24 through February 9, 1859 persons with gastroenteritis who required hospitalization and 66 deaths were reported to the MOH. Epidemiologic investigations are being carried out by FETP residents to further define the extent of the epidemic and the mode of transmission. As a result of the epidemic, a national permanent Committee of Epidemiologic Surveillance has been established. The general population has been alerted to ongoing activity, and information on preventive measures has been widely disseminated through the media. The MOH has recommended 1) the exclusive use of boiled water for drinking, 2) careful cleaning of fruit and vegetables, and 3) avoidance of raw or inadequately cooked fish or seafood. Reported by: C Vidal Layseca, MD, Minister of Health and Social Services, Lima; C Carrillo Parodi, MD, Director, National Institutes of Health, Lima; L Seminario Carrasco, MD, Director, General Office of Epidemiology, Lima; Field Epidemiology Training Program, Lima; Laboratory of Cayetano Heredia Univ, Lima, Peru. Navy Army Medical Research Institute Detachment, Lima, Peru. Enteric Diseases Br, Div of Bacterial Diseases, Center for Infectious Diseases; Global EIS Program, International Br, Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The appearance of cholera in several towns along the Peruvian seacoast represents the first time this century that epidemic cholera has been identified in South America. During the 19th century, epidemic cholera affected the Americas in several pandemic waves. The pandemic of cholera that began in Southeast Asia in 1961 affected many areas of Asia, the Middle East, Europe, Oceania, and Africa but apparently did not reach the American continents. An endemic focus of a unique Western Hemisphere strain exists along the coast of Louisiana and Texas, and possibly northern Mexico (1). Isolates from Peru are being examined to determine their relation to the pandemic or Western Hemisphere strains.

Following its introduction in sub-Saharan Africa in 1970, cholera was initially confined to coastal regions but spread following rivers and the routes of traders and travelers (2). The El Tor pandemic strain grows in many foods and can persist in aquatic environments. After initial outbreaks, cholera can disappear or become endemic and remain a public health threat. High attack rates are more common in areas with poor sanitation and inadequate water supplies. In previous epidemics, documented vehicles of transmission have included contaminated water, raw or undercooked shellfish and other seafood, moist-grain gruels, and leftover rice.

When the profuse watery diarrhea and vomiting associated with severe cholera are not treated, patients may die from dehydration in hours. Treatment with oral and, if necessary, intravenous rehydration can decrease death rates of severe cholera from 50% to 1%-2%. Therapeutic antibiotics can decrease the volume of stool produced. Mass chemoprophylaxis, vaccination, and quarantine have proven ineffective and can divert valuable resources from efforts to ensure adequate treatment of cases and control of transmission (3).

The impact of epidemic cholera can be diminished by organized control efforts. Public health officials should establish surveillance networks in areas with cholera, or at risk for cholera, and establish oral rehydration facilities throughout the country. Epidemiologic investigations, such as that being conducted by the Peruvian FETP (4,5) of the MOH, can help control efforts by determining the extent and source of outbreaks.

The risk to U.S. travelers of acquiring cholera in endemic areas is low. During the first 20 years of the current pandemic, only 10 cases of cholera in U.S. travelers were reported to CDC--representing a risk of acquiring a reported case of cholera of less than one per 500,000 returning travelers (6). Cholera vaccination confers only brief and incomplete protection and is not recommended. The usual precautions to prevent traveler's diarrhea should be observed carefully (7); particularly, raw seafood and potentially contaminated water should be avoided. A traveler who develops severe watery diarrhea, or diarrhea and vomiting, during or following travel to an area with known cholera should seek medical attention immediately.

References

1. Blake PA, Wachsmuth K, Davis BR, Bopp CA, Chaiken BP, Lee JV. Toxigenic Vibrio cholerae O1 strain from Mexico identical to United States isolates. Lancet 1983;2:912.

2. Goodgame RW, Greenough WB. Cholera in Africa: a message for the West. Ann Intern Med 1974;82:101-6.

3. World Health Organization. Guidelines for cholera control. Geneva: World Health Organization, 1986; publication no. WHO/CDD/SER/80.4 Rev 1.

4. Music SI, Schultz MG. Field Epidemiology Training Programs: new international health resources. JAMA 1990;263:3309-10.

5. Malison MD, Dayrit MM, Limpakarnjanarat K. The Field Epidemiology Training Programmes. Int J Epidemiol 1989;18:995-6.

6. Snyder JD, Blake PA. Is cholera a problem for US travelers? JAMA 1982;247:2268-9.

7. CDC. Health information for international travel, 1990. Atlanta: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8280.

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