Running head: VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH

Vibrio Cholerae Effects on Personal Health

Jessica Marie Ledesma

Angel Pico

Karla Franchesca Trabado

University Of San Agustin

Introduction

Cholera is a serious bacterial disease that usually causes severe diarrhea and dehydration.

This disease is typically spread through contaminated water. It is caused by eating food or

drinking water contaminated with a bacterium called vibrio cholera.

Clean water and sanitation have largely purged cholera from the developed world, yet

cholera continues to cause substantial suffering in a large portion of the globe. But as more

people move to the cities with teeming slums and population displacement due to wars, famine

or natural disasters occur, cholera will continue to be a problem as long as access to clean water

and sanitation is not assured.

After an absence of more than 25 years, cholera was again reported in the Philippines in

1961. Following the first reports of cases of Vibrio Cholerae O1 biotype El Tor in Manila in

1961, the Philippines has been considered as a cholera endemic country. It is estimated that there

are ∼18 million individuals at risk for cholera in the Philippines with an estimated annual

incidence of 0.1/1,000 persons at risk. However, data on cholera in the Philippines remain

sparse, since no systematic diarrheal disease surveillance existed that required laboratory

confirmation prior to 2008.

Cholera is on the rise with an estimated3 million to 5 million cases and 100,000-120,000

deaths per year worldwide. New more virulent and drug-resistant strains of vibrio cholera

continue to emerge, and the frequency of large protracted outbreaks with high case fatality ratios

has increased, reflecting the lack of early detection, prevention and access to timely healthcare.
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
3

Body

Cholera is an acute infection of the intestine, which begins suddenly with painless watery

diarrhea, nausea and vomiting. Most people who become infected have very mild diarrhea or

symptom-free infection. Malnourished people in particular experience more severe symptoms.

Severe cholera cases present with profuse diarrhea and vomiting. Severe, untreated cholera can

lead to rapid dehydration and death. If untreated, 50% of people with severe cholera will die, but

prompt and adequate treatment reduces this to less than 1% of cases.

Cholera is caused by the bacterium Vibrio cholerae. People become infected after eating food or

drinking water that has been contaminated by the feces of infected persons. Raw or undercooked

seafood may be a source of infection in areas where cholera is prevalent and sanitation is poor.

Vegetables and fruit that have been washed with water contaminated by sewage may also

transmit the infection if V. cholerae is present.

Control of cholera is a major problem in several Asian countries as well as in Africa. In the year

2000, some 140 000 cases resulting in approximately 5000 deaths were officially notified to

WHO. Africa accounted for 87% of these cases. After almost a century of no reported cases of

the disease, cholera reached Latin America in 1991; however, the number of cases reported has

been steadily declining since 1995.

Treatment of cholera consists mainly in replacement of lost fluids and salts. The use of oral

rehydration salts (ORS) is the quickest and most efficient way of doing this. Most people recover

in 3 to 6 days. If the infected person becomes severely dehydrated, intravenous fluids can be

given. Antibiotics are not necessary to successfully treat a cholera patient. According to the

official records on file at the Bureau of Health for the Philippine Islands, the last case of cholera
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
4

of the pandemic which commenced March 20, 1902, was reported to have occurred March 8,

1904. During that period 166,252 cases, with 109,461 deaths, were reported. Reliable observers

are of the opinion that at least one additional case occurred for each one that found its way into

the official records. From March 8, 1904, until Aug. 23, 1905, no cases are known to have

occurred. From time to time during this latter period suspicious cases, which clinically resembled

Asiatic cholera, came to the attention of the Insular Board of Health, but the diagnosis could not

be confirmed bacteriologically. For the two weeks immediately preceding August 23, the number

of suspicious cases increased. In Manila, one occurred in San Pedro Macati, a suburb; one in a

bakery in Paco; one in the San Miguel district; one case was that of a soldier in Cuartel de

España, and several in the province of Rizal. The cases in Manila were all carefully examined

postmortem, and the intestinal contents subjected to bactériologie tests by such competent

observers as Dr. R. P. Strong of the Government laboratory, and his assistants; and the case of

the soldier was carefully investigated by the military medical authorities, and specimens

examined at the Army laboratory which is maintained in connection with the First Reserve

Hospital of Manila. From both of these independent sources the results were reported as

negative. The first recognized case was on August 23. A case developed in Bilibid prison which

was a typical clinical picture of cholera. After a few hours the victim succumbed. At the

postmortem examination the ileum was found to be deeply injected and filled with rice-water-

like material, and the bactériologie examination made by Dr. R. P. Strong revealed the cholera

spirillum of Koch. Thus occurred the first officially recognized case of cholera of the present

outbreak. This patient was in an institution which is practically cut off from the remainder of the

world; where all foodstuffs are permitted to enter only after the most rigid inspection, and where

all food served, that could possibly convey cholera, is cooked at all times. On account of
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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dysentery, it is said that all drinking water was sterilized. Therefore, it would seem that the

routine precautions taken against dysentery should also have afforded protection against cholera.

The commencement of an outbreak in this insidious manner was most puzzling, and the

prospects of combating a disease whose origin was so obscure were not encouraging. On the

following day six cases, suspicious of cholera. were reported by Major Wales, from Fort William

McKinley, which is located about seven miles up the Pasig River, from Manila. For the week

preceding August 23, about eight cases, with profuse diarrhea and vomiting followed by

collapse, had occurred at the fort. The symptoms were the same as those usually found in vino

poisoning which is so common among the United States soldiers in the islands, and in the

absence of any cholera being reported anywhere in the Philippines, there was no particular

reason for investigating the cases further. In view of the fact, however, that the diagnosis of some

of the later cases that occurred at the fort was bacteriologically confirmed, the earlier diagnoses

of vino poisoning may not have been correct. The military medical men at once commenced

active measures, and the comparatively few days during which the cholera persisted at the fort is

another excellent example of how readily the disease can be eradicated when sanitary principles

are intelligently applied. On August 25 an American woman residing at the Grand Hotel, in the

walled city, was attacked, and died in a few hours. On the same day an American residing on San

Sebastian Street, in a section of the city nearly two miles from the previous patient, was seized

and died several hours afterward. No connection could be traced between the two cases, nor

could any history be obtained that the same articles of food, which would be likely to convey the

infection, had been eaten by these two victims. Cases in Manila occurred as follows:

August 23 2 September 1 17
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August 24 1 September 2 12

August 25 3 September 3 27

August 26 8 September 4 18

August 27 10 September 5 12

August 28 6 September 6 10

August 29 9 September 7 8

August 30 5 September 8 7

August 31 7 September 9 4

September 10 3

Table 1

From this period the cases averaged about one a day until the end of the year; the total cases,

from Aug. 23 to Dec. 31, 1905, inclusive, being 255. The characteristic tendency of the outbreak

continued during the early weeks of the scourge, viz.: No connection could be traced between the

cases; no two cases occurred in any one house, nor did two cases occur in any one group of

houses. A case almost invariably occurred in a section of the city far distant from a previous

case, and furthermore, it will be noted that the next case did not occur in the same section until

the likely incubation period had expired. Another especially noteworthy feature about the

outbreak is that while the greatest number of cases occurred in the slum district, this section of

the city was not infected until during the latter part of the outbreak. At the commencement of the

epidemic of 1902, cases in Manila were reported as follows:

March 20 4 March 30 11

March 21 6 March 31 6
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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March 22 4 April 1 17

March 23 8 April 2 4

March 24 14 April 3 13

March 25 15 April 4 13

March 26 12 April 5 9

March 27 11 April 6 11

March 28 6 April 7 9

March 29 5

Table 2

By comparing this table with Table 1, it will be seen that at the end of the second week there had

actually been more cases during the outbreak of 1905 than during that of 1902. In the meantime,

a telegram received August 26 from Jalajala, province of Rizal, through the Army Medical

Department, contained the following information: Cases of a disease resembling cholera have

developed in Jalajala, the first case being registered on the 21st; from that date to the 25th, 16

cases and 12 deaths have been registered, the illness lasting from twelve to twenty-four hours.

On August 26 another telegram, received from the president of the Provincial Board of Health at

Pasig, reported one suspicious case followed by death, in that town. A representative of the

Insular Board of Health, and another from the Bureau of Government Laboratories, proceeded at

once by special launch to Pasig and Jalajala, for the purpose of investigating the cause of the

outbreak in these places. The result of this investigation did not shed any light on the origin of

the infection. Inquiry made by the inspectors only resulted in showing that at least one week

prior to August 23 more deaths had occurred in Jalajala than usual, and that the victims had

profuse diarrhea and died a few hours after the symptoms manifested themselves. An
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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investigation made by Dr. L. T. Hess, captain and assistant surgeon. United States Army, of the

records on file at Muntinlupa and Binan, situated in Rizal and Laguna provinces, respectively,

and on the opposite shore of Lake Laguna from Jalajala, showed that death certificates had been

filed during the week preceding August 23, for a number of cases (less than 12), in which the

cause of death was given as "suspicious diarrhea." The following table will show the order in

which other towns in the provinces became infected and the number of cases up to Jan. 1, 1906 :

Table 3
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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The cases and deaths in the city of Manila, from August 23 to December 31, were distributed by

age as follows:

Table 4

The number of cases of cholera that occurred by race, between Aug. 23, 1905, and Dec. 31,

1905, and the date of the last case, are shown in Table 5. Table 6 shows the classification of

cases by occupation.

Table 5
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Table 6

Prom Table 5 it will be seen that in proportion to their number, more foreigners (Japanese

and Europeans) contracted cholera than any other nationality: that the Americans ranked next,

but had the lowest death rate, and that the least number occurred among the Chinese. The

mortality of 100 per cent, among Chinese may be attributed to the fact of the very few cases that

occurred, and that those patients who recovered probably escaped detection by the health

authorities. That no further cases occurred among Americans after October 10 was probably due

to the fact that as soon as they believed the disease to be actually present, they observed the

prophylactic measures against cholera more strictly. The high percentage of Americans and

Europeans attacked may also be more apparent than real, because it is quite probable that all

those persons of this race who were attacked promptly sought medical advice and thus were

reported, while among the natives and Chinese, in all probability cases occurred in which the

patient recovered, and thus were not reported. It will now be interesting to consider whether or
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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not the Infection was introduced from without, and in this connection it will be important to

ascertain in what other nearby countries cholera was present at the time it made its appearance in

the Philippine Islands. Manila is in active communication, by direct steamship lines, with the

following Oriental ports: Yokohama, Kobe, Nagasaki, Mpji, Shanghai, Amoy, Hong Kong,

Saigon, Singapore, Rangoon, Calcutta, Madras and Bombay, and indirectly, with Sourabaya and

few other Javanese and Bornean ports. Examination of the official sanitary statistics received

from the ports mentioned discloses the fact that cholera was present in an isolated manner in the

country back of Kobe, Japan; in Calcutta and in Bombay. In the case of the two last mentioned

ports, the sailing time to Manila by the most direct steamers is at least nine or ten days from

Calcutta, and at least fifteen days from Bombay. The fact that the incubation period is only five

days, that no sick was found on any of these vessels, and that, from laboratory experience, it has

been ascertained the class of vegetables and other cargo which come from these ports will not

serve as media for the growth of the cholera bacilli for a greater period than five days, shows that

for practical purposes these two ports may be dismissed from further consideration. At any rate,

the only importations from India are rice, onions, potatoes, textiles, ivory goods and other

articles not at all likely to convey cholera organisms. No cholera was reported in Hong Kong,

and none was known to exist in Canton, but in view of the fact that the actual status of the public

health in Canton is not well known at any time, that place cannot be excluded with any degree of

positiveness. The time from Canton to Manila, by way of Hong Kong would be at least from four

to five days, but in view of the fact that only onions, potatoes, garlic and such other vegetables as

are necessarily forwarded in a dry state, were shipped from these ports, it is not likely that

cholera organisms could have been introduced with them ; furthermore, since Canton vegetables

are used freely aboard vessels which entered the Philippines from Hong Kong, and since no sick
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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were found on these vessels, it is reasonable to exclude that port from the list of places likely to

have been the cause of the introduction of the infection. The records show that from Kobe a

number of vegetables were shipped, but they consisted principally of onions and potatoes, and a

very small amount of cabbage. The vessels that arrived from that port for the month preceding

the outbreak of cholera in Manila did not have any cases aboard which were in any way

suspicious of cholera. In view of the fact that cabbage is the only vegetable which could possibly

have been the cause of the introduction of cholera, and since at least five days is consumed in the

voyage, and more time must necessarily have elapsed before it could have been placed on the

market, and since experiments made in the laboratory of the Public Health and Marine-Hospital

Service show conclusively that cholera organism cannot be kept alive on cabbage for longer than

five days, this method of the introduction of the infection may also be excluded. The only other

articles which are open to suspicion, imported from Kobe, Japan, are classes of food peculiar to

the Japanese, and which are not eaten by other nationalities. Many of these consist of vegetables

in a fermented state, which in itself precludes the probability of cholera organisms existing

therein; and furthermore, since no Japanese persons are known to have been attacked in the city

of Manila until the disease was present at least five days, and after more than 25 cases had

occurred among other nationalities, it is not likely that the infection can be ascribed to Japanese

food products. From the foregoing it will be observed that so far as the records show, at least, it

is not likely that the infection gained entrance into the Philippine Islands from without. Of

course, there is always the possibility that cholera organisms may have been present in the

intestines of an incoming passenger, but in view of the fact that the first cases known to have

occurred were in persons known to have been in the islands many weeks immediately previous,

and also, that they were not persons likely to ingest foreign food, this last contingency would
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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also seem remote. In mapping out a campaign for the suppression of the disease, the work was

divided into four parts: 1. Isolation of the sick in the cholera hospital, and the rigid disinfection

of their houses and effects. 2. The protection of the city water supply, including the closing of

wells located in the city of Manila. 8. Prohibition of the sale of foodstuffs likely to become

contaminated, and the proper protection, with fly screens, of the remainder. 4. The education of

the public in the precautions to be observed in order to avoid the disease. The carrying into effect

of the isolation of the sick, and their treatment at the cholera hospital, was so well organized as

the result of the experience gained in the former epidemic that this particular feature worked very

smoothly; but in other respects the work was attended with considerable difficulty on account of

the strong antipathy of the Filipinos to be treated elsewhere than in their homes. The native daily

papers took the matter up and drew a vivid pen picture of the mental agony that would be

endured by the relatives and friends of those who should be unfortunate enough to be stricken

with cholera, and separated from them by being compelled to go to the cholera hospital. The

direct effect of the publication of such articles was that many cases were concealed, and just so

many infected centers remained undiscovered. The newspaper attacks were borne patiently, and

constant endeavors made to show prominent Filipinos and the representatives of the press the

magnificent manner in which the cholera hospital was equipped, and how much the chances of

recovery from an attack were increased by hospitalization, and the fact was particularly pointed

out of the great injustice done to the patient by depriving him of these increased chances for

recovery. Fortunately, a number of well-known citizens recovered at the cholera hospital about

this time, which had the effect of at least silencing the critics, after which the work of isolation

was carried on with much less hindrance and with ever-increasing effectiveness. To the

American press of Manila too much credit cannot be given for the manner in which it pointed out
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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the danger that existed in concealing cases. No attempt was made to quarantine "contacts," nor

was any attempt made to institute a land quarantine at any place in the islands. This was a radical

departure from- the manner in which, in 1902, the campaign against cholera was conducted. The

infection was followed from center to center; the sick were isolated, and every practicable

measure was taken to destroy the infection and thus to prevent its spread. It is believed that this

method was of more value than an attempted quarantine would have been, as the latter would

necessarily have had to be too despotic to have been of any permanent value. The policy was to

educate rather than to antagonize, and what has been lost in some respects has been more than

compensated for in others. By comparing the disease during this epidemic, with that of the

previous one, it will be seen that the disease actually spread more slowly this time than before.

To quarantine effectually the infected area in and around Manila, not to mention the provinces,

would have required from 30.000 to 50,000 armed men, and unless this quarantine had been

made effective, it would have been useless. The cost of maintaining such a quarantine, in the

salaries for guards and delays and losses to business, would have been enormous. It may be

contended that the infection this time was milder in character, and for that reason did not spread,

but when it is remembered that the mortality was over 90 per cent., and that nearly all the victims

succumbed in a few hours after the first symptoms appeared, and that almost without exception

the disease spread rapidly unless prompt disinfection was done, it will be seen that this

contention has very little basis in fact. The beneficial effect of not alarming the populace, and

thereby causing a great emigration from the centers in which the disease appears, can scarcely be

overestimated. By the plan followed, cases of cholera, instead of being carried far and wide in

every direction, were confined largely to Manila, where the patients could be promptly isolated

and the necessary disinfection performed; the consequence of which, of course, was that there
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
15

was little danger from the spread of infection in such cases. The one idea that was kept

constantly in mind was to so arrange the inspection system that the disinfectors could reach the

cases in the shortest possible time. The disinfection was made as simple as possible, and strict

instructions issued that nothing must be destroyed or damaged, with the exception of the

prepared food which was found in the houses; the stools of the patients and the places where they

were thrown and the clothes whiff they soiled were diligently sought for and thoroughly

disinfected with a 1 to 1,000 solution of bichloride of mercury, or a 5 per cent, solution of

carbolic acid. The floors and walls were thoroughly saturated with the same solution, by means

of a pump. All containers in which water was stored, as, for instance, water coolers, earthen jars,

filters, barréis, wells, etc., were treated with potassium permangante. "Contacts" were required to

take an antiseptic bath. The disinfecting carts were used in much the same way as the apparatus

of a fire department. The horses were kept hitched up, night and day, and as soon as a case was

reported, the disinfectors reached the infected house a few minutes later. The fact that no second

case occurred in any house shows most effectively how efficiently the disinfection was done. A

few days after the outbreak of cholera in Manila, a few isolated cases of the disease were carried

to the water-shed from which Manila obtains its drinking water. These cases probably came from

Taytay, a small town in Rizal province, located near the watershed. The importance of properly

guarding the water supply of a city of 219,000 inhabitants will be readily appreciated.

Arrangements were promptly made for. sending an adequate patrol to the Mariquina Valley, to

prevent the pollution of the water. Through the courtesy of the Commanding General of the

Philippines Division, four troops of the Eighth Cavalry were promptly ordered to the valley, and

remained there until long after the time that the last case of cholera was reported. The water-shed

is inhabited by about 10,000 persons, and from time immemorial it has been their custom to
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
16

bathe and wash in the Mariquina River, from which the Manila water supply is drawn. To

deprive them, suddenly, of this privilege produced great opposition among the people, and made

it difficult for effective work to be done. For that reason, to the American troops great credit is

due on account of the great patience which they exercised. The fact that the river was not

polluted, although many cases of cholera occurred immediately along its banks, shows most

conclusively how effectively the troops carried out the duties to which they were assigned. As an

additional protection, during the time that the cholera on the water-shed was at its height it was

deemed advisable to place a sufficient amount of copper sulphate in the city reservoirs to make a

solution of 1 to 2,000,000. Subsequent experiments made at the laboratory with the regular city

water, however, showed that a solution of at least 1 to 50,000 would be required to kill cholera

organisms with certainty in thirty minutes' time. As this would be unsafe for drinking purposes,

for continual use, it is of course obvious that cholera organisms cannot be successfully removed

from the public water supply of Manila by the use of copper sulphate. In the city of Manila there

still remain a great many wells which, ostensibly, are used only for the purpose of sprinkling

streets, washing carriages and other uses; but the danger is always present that they will be used

for drinking purposes, and for that reason an order was issued which directed the closing of all

wells in the city of Manila. After the large city mains were protected, and the wells were closed,

it could almost be said with certainty that no large epidemic could take place in the city of

Manila, and this proved to be the case.

Conclusion

Our findings confirm that cholera affects a large proportion of the provinces in the

country. Identifying areas most at risk for cholera will support the development and

implementation of policies to minimize the morbidity and mortality due to this disease.
VIBRIO CHOLERAE EFFECTS ON PERSONAL HEALTH
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References

Lopez AL, Macasaet LY, Ylade M, Tayag EA, Ali M (2015) Epidemiology of Cholera in the

Philippines. PLoS Negl Trop Dis 9(1): e3440. https://doi.org/10.1371/journal.pntd.0003440

Illinois Institute for Addiction Recovery. (n.d.). Opiates Addiction. Retrieved March 8, 2019,

from http://www.addictionrecov.org/Addictions/?AID=39

Reidl J, Klose KE. Vibrio cholerae and cholera: out of the water and into the host. FEMS

Microbiol Rev. 2002;26:125-39.

https://www.who.int/water_sanitation_health/diseases-risks/diseases/cholera/en/