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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

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2018 Impact Factor: 1.847

Front. Med.    2019, Vol. 13 Issue (2) : 213-228
Cholera: an overview with reference to the Yemen epidemic
Ali A. Rabaan()
Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
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Cholera is a secretory diarrhoeal disease caused by infection with Vibrio cholerae, primarily the V. cholerae O1 El Tor biotype. There are approximately 2.9 million cases in 69 endemic countries annually, resulting in 95 000 deaths. Cholera is associated with poor infrastructure and lack of access to sanitation and clean drinking water. The current cholera epidemic in Yemen, linked to spread of V. cholerae O1 (Ogawa serotype), is associated with the ongoing war. This has devastated infrastructure and health services. The World Health Organization had estimated that 172 286 suspected cases arose between 27th April and 19th June 2017, including 1170 deaths. While there are three oral cholera vaccines prequalified by the World Health Organization, there are issues surrounding vaccination campaigns in conflict situations, exacerbated by external factors such as a global vaccine shortage. Major movements of people complicates surveillance and administration of double doses of vaccines. Cholera therapy mainly depends on rehydration, with use of antibiotics in more severe infections. Concerns have arisen about the rise of antibiotic resistance in cholera, due to mobile genetic elements. In this review, we give an overview of cholera epidemiology, virulence, antibiotic resistance, therapy and vaccines, in the light of the ongoing epidemic in Yemen.

Keywords cholera      epidemic      multi-drug resistant      catechin      luteolin      ToxT      CTXФ     
Corresponding Authors: Ali A. Rabaan   
Just Accepted Date: 16 April 2018   Online First Date: 21 June 2018    Issue Date: 28 March 2019
 Cite this article:   
Ali A. Rabaan. Cholera: an overview with reference to the Yemen epidemic[J]. Front. Med., 2019, 13(2): 213-228.
Fig.1  Overview of V. cholerae classification by serogroup and biotype.
Year Location References
2008 Mozambique (9087 cases); Zimbabwe (2008−2009; 98 522 cases) [30, 44]
2009 DRC; Mozambique (19 679 cases); Zimbabwe (continued from 2008); Tanzania (7700 cases); Kenya (11 769 cases) [30, 39, 44]
2010 HAITI (epidemic begins October; approximately 700 000 cases to date); Zimbabwe (Kadoma City, 127 cases); Cameroon (2010−2011; 23 152 cases); Nigeria (41 787 cases); Bangladesh (MDR resistance rising— 93% of isolates from coastal areas 2010−2014— approximately 450 000 cases/year); India (El Tor variant; 2152 cases) [4, 29−31, 43, 44, 50, 51, 63]
2011 Philippines (O1 hybrid El Tor; Palawan, 1226 cases); DRC (8038 cases); Uganda (fishing villages— recurrent yearly outbreaks 2011−2015, 5059 cases); Cameroon (continued from 2010) [36−39, 48]
2012 Guinea (2009−2012,>15 500 cases) ; DRC (Betou, 355 cases); Tanzania; India (El Tor ctxB7 allele) [37, 39, 47]
2013 India (MDR O1 Ogawa, Bagalkot, 49 cases); Tanzania (Dar Es Salaam, approximately 3400 cases) [37, 52]
2014 Ghana (Accra region, continued into 2015, more than 20 500 cases) [37]
2015 Tanzania (approximately 9900 cases); Southern Sudan (began 2014; insufficient vaccines; 2260 cases) [37, 40]
2016 YEMEN (epidemic begins October; ongoing); Tanzania [9, 37]
2017 Surge in cases in Yemen since April; 862 858 suspected cases (26/10/17 WHO update) [9]
Tab.1  Timeline of large cholera outbreaks in last decade
Target Therapeutic agent Therapeutic target/mechanism References
Virulence/toxin mediators Seaweed polysaccharide (in vivo-mice) CT; GM1 receptor [100]
Anethole (in vitro, in vivo-rabbits) Reduced CT and TCP expression via inhibition of ToxT [101]
Catechin and luteolin (in silico) Inhibition of ToxT [102]
Conjugated linoleic acid (CLA) (in vitro, in vivo-rabbits) Reduced CT and TCP expression via inhibition of ToxT [111]
Virstatin (in vitro, in vivo- mice) Reduced CT expression via inhibition of ToxT [113]
Model bicyclic compounds (in vitro) Reduced in vitro tcp expression via inhibition of ToxT [110]
Ribavirin (in vitro) Inhibition of AphB [106]
Dietary minerals (Zn, Mg, Se) (in vitro, ex vivo) Reduction of transcription virulence genes ctxAB, fliA, ?toxR [114]
Lytic bacteriophages ØVC8 (wastewater, Mexico) Lytic activity against V. cholerae O1 strain [108]
VPUSM 8 (sewage water, Malaysia) Lytic activity against V. cholerae O1 El Tor Inaba ?serotype [109]
ICP 1, 2 and 3 (in vitro, in vivo-mice) Lytic activity against V. cholerae O1 [107]
Host-directed CFTR inhibitor ®-BPO-27 (in vitro, in vivo-mice) Inhibition of CFTR conductance [104]
Bithionol (caspase inhibition) (in vitro) Reduction of CT effects via inhibition of human ?caspases-1, -3, -6, -7, -9 [112]
Entinostat (in vitro, in vivo-rabbits) Restoration of antimicrobial peptide CAP-18 levels [105]
Quorum sensing Manipulation of the gut microbiota [103]
Tab.2  Overview of potential cholera therapies
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