13663

	va1-sg19016.securesites.net

	autolearn=disabled version=3.1.8





************************************************



Asia

[2] Cholera - Iraq (northern)

[3] Cholera - India (Orissa)



******

(OCHA), ReliefWeb, WHO report [edited]





Since 23 Aug 2007, a 3 to 4 fold increase of acute watery diarrhea 

cases were being reported from one of the teaching hospitals of 

Sulaymaniyah province in Northern Iraq. Laboratory tests performed on 

stool specimens confirmed _Vibrio cholerae_ serogroup O1 biotype 

Inaba as the causative pathogen for these reported acute watery diarrhea cases.



So far between 23 Aug 2007 and 2 Sep 2007, the cumulative number of 

cases of acute watery diarrhea reported from 4 out of 11 districts of 

Sulaymaniyah province stands at 2930 including 9 deaths with an 

overall case fatality rate (CFR) of 0.30 percent. Of these reported 

cases, _Vibrio cholerae_ has been laboratory confirmed in 187 stool samples.



_Vibrio cholerae_ serogroup O1 biotype Inaba was isolated from a 

stool specimen for the 1st time ever on 19 Aug 2007 from Kirkuk 

province of Northern Iraq where stool specimens are routinely 

collected and tested for detecting enteric pathogens as part of 

routine surveillance for diarrheal diseases, which is in place in all 

hospitals of the province. Despite the fact that no discernible 

increase in the caseload of acute diarrhea has been observed between 

2 comparable periods of 2007 and 2006, a total of 2968 cases of acute 

diarrheal syndrome including one death (CFR = 0.033 percent) were 

reported from Kirkuk province between 29 Jul 2007 and 26 Aug 2007. Of 

these reported cases, _Vibrio cholerae_ has been isolated from stool 

specimens of 101 cases.



As of 1 Sep 2007, the outbreak, since reported on 23 Aug 2007, has 

spread to 4 out of 11 districts in the province [for map, see URL of 

full report below - Mod.LL] exposing over 1 502 000 people at great 

public health risk. No surveillance system for diarrheal diseases 

existed in the province before the outbreak started on 23 Aug 2007. 

Only recently with support from the WHO Office of Iraq, the 

provincial health authority has started collecting surveillance data 

on cases reported to the health centers and hospitals. Therefore, due 

to inadequacy of reporting and other limitations of the surveillance 

system, the cumulative number of cases of cholera reported so far 

from the province may be grossly underreported and may not represent 

the true burden of the disease.



The available report suggests that the outbreak initially started in 

Sulaymaniyah district and then spread to other 3 districts (Rania, 

Halabja, and Chamchamal). Apart from these 4 districts, no laboratory 

confirmed case of _Vibrio cholerae_ has, so far, been reported from 

any of the remaining 6 districts of the province. It is unclear at 

this stage what has been the source of infection for this current 

wave of cholera in the province.



The daily progression of cases as shown in Figure 1 [see URL for full 

report - Mod.LL] does not reflect any particular cyclical trend. The 

several spikes that are shown in the epi curve may be due to 

incomplete reporting as well as inadequacy of reporting. As the 

surveillance system improves and better quality data are available 

form the field, better understanding on the trends as well as on the 

progression of the outbreak over time would be possible. Recent 

information received from the field suggests that the number of 

severe cases with symptoms and signs of cholera/acute watery diarrhea 

reporting to health centers and hospitals might have been dropping as 

compared to the previous week, but cumulative numbers are, probably, 

increasing since the surveillance coverage is expanding with more and 

more health centers reporting on a daily basis and due to increased 

public awareness, more and more cases with mild symptoms and signs 

synonymous with symptoms of cholera are reporting to health centers. 

Nevertheless, given the data that are available, it clearly shows 

that the transmission is still continuing and likely to spread to 

other adjoining districts and the risk of exposure would prevail 

unless the control measures can specifically target areas, which 

remain within the epicenter of this current outbreak.



As the information flow improves over the next couple of days, public 

health risk assessment of the current situation could possibly be 

done through a more comprehensive analysis of the current 

epidemiological situation.



--



[As a short review, the flagellar (H) antigens of _V. cholerae_ are 

shared with many water vibrios and therefore are of no use in 

distinguishing strains causing epidemic cholera. The O (somatic) 

antigens, however, do distinguish strains of _V. cholerae_ into 139 

known serotypes. Almost all of these strains of _V. cholerae_ are 

nonvirulent. Until the emergence of the Bengal (O139) strain (which 

is "non-O1"), a single serotype, designated O1, has been responsible 

for epidemic cholera.



There are 3 distinct O1 biotypes, named Ogawa, Inaba, and Hikojima, 

each of which may display the "classical" or El Tor phenotype. The 

biotypes are distinguished by their expression of surface antigens A, 

B, and C. Ogawa contains antigens A and B, Inaba A and C) and 

Hikojima antigens A, B, and C). The latter serotype is relatively rare.



The full report with the mentioned map and figure can be found at

- Mod.LL]



******

[2] Cholera - Iraq (northern)





The World Health Organization said on Tue 4 Sep 2007, thousands of 

people had fallen ill with cholera in northern Iraq, but the cause of 

the outbreak had not been identified. "The source of infection is 

very unclear so far," said Claire Lise Chaignat, head of the United 

Nations agency's global task force on cholera control.



Health officials in Iraq's semi-autonomous Kurdistan region said last 

week [27 Aug-2 Sep 2007] that a Sulaymaniyah water treatment plant 

had tested positive for the bacterium that caused cholera, and that 

its filters would be cleaned. Polluted well water was also cited as a 

possible infection source. In Kirkuk, cracked water pipes allowing 

contamination by sewage were blamed for the outbreak.



According to the WHO website, sudden large outbreaks of cholera are 

usually caused by a contaminated water supply. The diarrheal disease, 

which also causes severe vomiting, is rarely transmitted by direct 

person-to-person contact.



Chaignat said it appeared that the number of cases in Sulaymaniyah 

may have been decreasing over the past week, but stressed it was 

possible that cholera would continue to spread. She said health 

workers in the region "so far" have had the resources they need to 

confront the outbreak. Most cholera cases are treated with oral 

rehydration salts, though some patients require intravenous fluids or 

antibiotics.



--



[A map of Iraq showing the areas involved in the northern area 

sometimes referred to as Kurdistan can be found at



and Jordan 

established border watches related to cholera. As can be seen, only 

the Turkish border, however, is anywhere close to the currently 

affected areas in the north of the country. - Mod.LL]



******

[3] Cholera - India (Orissa)

(OCHA), ReliefWeb, Agence France-Presse (AFP) report [edited]





The death toll from an outbreak of cholera in eastern India rose to 

169 with thousands of people being treated for the disease, officials 

said Tue 4 Sep 2007. Government administrators in 4 affected 

districts, 500 kilometers (310 miles) southwest of impoverished 

Orissa state's capital Bhubaneswar, supplied the toll, disputed by 

opposition parties and aid workers.



The health control room in Bhubaneswar set up to monitor the outbreak 

of the disease said more than 5000 people were being treated for 

cholera and dysentery, according to a government spokesman. But 

representatives of ActionAid in Orissa challenged the figures put out 

by the government, saying the death toll was closer to 250, while 

state opposition parties put it at almost 500.



"Local sources have told ActionAid that nearly 250 people have died," 

ActionAid worker, Bratindi Jena, said. She accused the authorities of 

keeping the toll artificially low. "If the government reveals the 

true figure, they would have to offer compensation (of 10 000 rupees 

or USD 240) to many more families," the ActionAid statement quoted 

Jena as saying.



--



[The location of this quite large and growing Indian outbreak of 

cholera following a typhoon in Orissa can be found at

- Mod.LL]



2006

----

...................................ll/mj/dk