Global & Disaster Medicine

Archive for the ‘Cholera’ Category

Yemen: 23 425 new suspected cases of cholera and 242 related deaths


Weekly update – cholera in Yemen, 20 May 2017

20 May 2017 – The Ministry of Public Health and Population of Yemen has released updated numbers of cholera cases in the country. Since the last update on 27 April, 23 425 new suspected cases of cholera and 242 related deaths (case-fatality rate 1.1%) have been reported, mainly from Amran, Hajjah and Sana’a governorates and Sana’a city.

A cumulative total of 49 495 suspected cases of cholera, including 362 associated deaths have been reported across the country since the outbreak started in October 2016. However, between 27 April and 18 May 2017, there has been a significant upsurge in the number of suspected cholera cases. The outbreak has spread to around 210 districts in 18 governorates across the country, and the case fatality rate has exceeded 1%.

WHO has intensified the cholera response activities to mitigate the outbreak, including the establishment of 4 cholera treatment and 16 oral dehydration centres, training of health workers to manage the cases, deployment of rapid response team to manage cholera cases investigations and respond to the outbreak, enhancement of Yemen’s disease early warning surveillance systems, and provision of emergency medical supplies to treatment facilities.

The ongoing response operations are severely hampered by limited active case-finding, population movement and displacement, poor accesses to health care services, food insecurity and malnutrition.

Cholera has killed at least 115 people in the Yemeni capital Sanaa after authorities on Sunday declared a state of emergency over the outbreak and called for international help to avert disaster.



WHO and partners are responding to an upsurge in cholera transmission in several parts of Yemen that has claimed 51 lives and caused around 2752 suspected cases since 27 April 2017.


WHO responds to resurgent cholera in Yemen

WHO responds to resurgent cholera in Yemen

11 May 2017, Sana’a, Yemen — The World Health Organization (WHO) and partners are responding to an upsurge in cholera transmission in several parts of Yemen that has claimed 51 lives and caused around 2752 suspected cases since 27 April 2017.

WHO has rapidly distributed medicines and medical supplies, including cholera kits, oral rehydration solutions and intravenous (IV) fluids as well as medical furniture and equipment for diarrhoea treatment centres. Ten new treatment centres are being established in affected areas.

WHO is also supporting health authorities to establish oral rehydration therapy corners to treat mild and moderate dehydration due to diarrhoea. Starting with 10 oral rehydration therapy corners in Sana’a, this approach will be replicated across all affected areas. More severe cases will be referred to the diarrhea treatment centres.

“We are very concerned with the re-emergence of cholera across several areas of Yemen in the past couple of weeks. Efforts must be scaled-up now to contain the outbreak and avoid a dramatic increase in cases of diarrhoeal disease,” said Dr Nevio Zagaria, WHO Representative in Yemen.

Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholera. Most of those infected will have no or mild symptoms but, in severe cases, the disease can kill within hours if left untreated.

The uptick in cholera cases comes as Yemen’s already weakened health system struggles under the weight of two years of conflict. Key infrastructure, including water and sanitation facilities, are collapsing, contributing to the spread of diarrhoeal disease. The weather is also playing a role: the pathogens that cause cholera are more likely to spread in warmer weather and recent heavy rains have washed piles of uncollected waste into water sources.

The cholera outbreak in Yemen was announced by Yemen’s Ministry of Public Health and Population (MoPHP) on 6 October 2016. WHO estimates that 7.6 million people live in areas at high risk of cholera transmission.

Prior to this recent resurgence, WHO had supported the rehabilitation of 26 diarrhoea treatment centers in the affected governorates and trained health workers to treat patients based on WHO case management, infection prevention and control standards. The Organization has also trained and supported the deployment of rapid response teams to investigate potential cases and chlorinate water sources in areas where cholera has been reported.

WHO continues to support the efforts of health authorities in enhancing diagnosis capacity, strengthening the disease surveillance system, delivering medicines to high-risk areas, organizing health education campaigns for at-risk populations and training national staff on case management and early detection and reporting.

“WHO is in full emergency mode to contain the recent upsurge of suspected cholera cases,” continued Dr Zagaria. “Containing the spread of the outbreak is a high priority for WHO and we are coordinating efforts with all parties and with our health, water and sanitation partners to scale up an integrated and effective response to the cholera epidemic.”

WHO calls for immediate action to save lives in Somalia


News release

WHO is concerned by the chronic shortage of funding for life-saving work in Somalia in response to the ongoing drought that has plunged the country further towards famine, disease, and health insecurity. Drought in Somalia led to the destruction of crops and livestock, leaving more than 3.3 million people hungry every day. If the current situation continues, famine could soon be a reality, creating a devastating cycle of hunger and disease as the health of people deteriorates and they become more susceptible to infection. Drought has also led to lack of clean water and the largest outbreak of cholera Somalia has seen in the last 5 years, with more than 36 000 cases and almost 690 deaths so far in 2017 alone. With the beginning of the expected rainy season and floods this month, these numbers are expected to increase to 50 000 cases by the end of June. Cases of measles are also on the rise, with nearly 6 500 cases reported this year, 71% of them children under the age of 5 years.

“History has shown the terrible consequences of inaction, or action that comes too late. More than a quarter of a million lives – half of them children – were lost as a result of the devastating famine of 2011. This year, a much larger percentage of the population is now at risk. We will not stand by and watch millions of already vulnerable men, women, and children become victims of an avoidable catastrophe,” said Dr. Peter Salama, WHO Executive Director for Emergencies.

WHO commends the Government of the United Kingdom for its leadership in hosting an international conference today to tackle the country’s most urgent challenges, and calls on the international community to take decisive action to help avoid a humanitarian catastrophe. So far in 2017, health sector requirements of US$ 103 million are only 23% funded and WHO has received less than 10% of US$ 25 million required for an organizational response. WHO urgently appeals for additional support from the international community to ensure the health response can continue and expand, to save lives and alleviate the suffering of millions of Somalis.


Whilst the operating environment in Somalia remains challenging, and humanitarian access restricted as a result of ongoing conflict and violence in many parts of the country, WHO and health partners continue to scale up their response, with coordination hubs established in Mogadishu, Garowe, Hargeisa and Baidoa. In March and April 2017, WHO delivered nearly 50 tons of medicines and medical supplies to provide life-saving support for almost 4.3 million people. Cholera treatment centres are now operational in 40 districts, and the numbers of surveillance sites for epidemic-prone diseases have been increased across the country, with Rapid Response Teams deployed to support investigation and response activities. In March, WHO and partners conducted the first national oral cholera vaccination campaign in Somalia, reaching over 450 000 vulnerable people. A second campaign is ongoing in South West State and Middle Shebelle, targeting 463 000 vulnerable people.

Travel, cholera, and CVD 103-HgR


Recommendations of the Advisory Committee on Immunization Practices for Use of Cholera Vaccine

Karen K. Wong, MD1; Erin Burdette, MPH1; Barbara E. Mahon, MD1; Eric D. Mintz, MD1; Edward T. Ryan, MD2; Arthur L. Reingold, MD3


Cholera, caused by infection with toxigenic Vibrio cholerae bacteria of serogroup O1 (>99% of global cases) or O139, is characterized by watery diarrhea that can be severe and rapidly fatal without prompt rehydration. Cholera is endemic in approximately 60 countries and causes epidemics as well. Globally, cholera results in an estimated 2.9 million cases of disease and 95,000 deaths annually (1). Cholera is rare in the United States, and most U.S. cases occur among travelers to countries where cholera is endemic or epidemic. Forty-two U.S. cases were reported in 2011 after a cholera epidemic began in Haiti (2); however, <25 cases per year have been reported in the United States since 2012.

In 2016, lyophilized CVD 103-HgR (Vaxchora, PaxVax, Redwood City, California), a single-dose, live attenuated oral cholera vaccine, was approved by the Food and Drug Administration for the prevention of cholera caused by V. cholerae O1 in adults traveling to cholera-affected areas. Lyophilized CVD 103-HgR is the only cholera vaccine licensed for use in the United States. In June 2016, the Advisory Committee on Immunization Practices (ACIP) voted to recommend use of lyophilized CVD 103-HgR for prevention of cholera among adult travelers to areas with endemic or epidemic cholera caused by toxigenic V. cholerae O1, including areas with cholera activity during the last year that are prone to recurrence of cholera epidemics. ACIP considered evidence on safety and efficacy of the currently available formulation of CVD 103-HgR as well as that of a previously available formulation with identical phenotypic and genomic properties that was licensed and marketed in other industrialized countries before manufacture ceased in 2003 for business reasons (i.e., not because of safety or efficacy concerns) (3,4). This report provides new recommendations and guidance for vaccination providers and travelers about the use of lyophilized CVD 103-HgR. These recommendations apply to adults aged 18–64 years traveling to areas with endemic or epidemic cholera.


ACIP work groups meet regularly to review all relevant data and prepare draft policy recommendations for ACIP consideration. Work groups are chaired by an ACIP member and include at least two ACIP members and a CDC subject matter expert; relevant ex officio members, liaison representatives, members of academia, other CDC staff members, and consultants are included as needed (5). In addition to ACIP members and CDC participants, the Cholera Vaccine Work Group (Work Group) includes participants from the Department of Defense, the Infectious Diseases Society of America, the National Foundation for Infectious Diseases, and academia. Members include experts in cholera, travel medicine, immunology, infectious diseases, obstetrics and gynecology, epidemiology, public health, military health, immunization safety, vaccine policy, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, a framework for evaluating scientific evidence. The Work Group convened monthly teleconferences starting in August 2015 to review cholera epidemiology and the evidence for the efficacy and safety of CVD 103-HgR according to the GRADE approach ( During teleconferences, the Work Group reviewed and discussed a summary of findings and evidence quality for relevant outcomes. Questionnaires were used to collect and summarize Work Group opinions on key outcomes, evidence type, and proposed recommendations.

At the October 2015 ACIP meeting, the Work Group presented an overview of cholera epidemiology and CVD 103-HgR to ACIP. At the February 2016 meeting, the Work Group presented the GRADE review that summarized the strength of evidence for each of the outcomes assessed (prevention of cholera death, life-threatening cholera diarrhea, severe cholera diarrhea, and cholera diarrhea of any severity; induction of vibriocidal antibody response; occurrence of serious and systemic adverse events; and impact on effectiveness of co-administered vaccines and medications; ( At the June 2016 meeting, the Work Group presented proposed recommendations, and after a public comment period, ACIP voted to approve recommendations for use of lyophilized CVD 103-HgR. Postmarketing surveillance studies and additional data pertaining to use of the vaccine will be reviewed by ACIP as they become available, and recommendations will be updated as needed.

Summary of Findings

Lyophilized CVD 103-HgR is the only cholera vaccine licensed for use in the United States. Its efficacy against severe diarrhea (defined here as fecal output >3 L/24 hours) after oral toxigenic V. cholerae O1 challenge is estimated to be 90% at 10 days after vaccination and 80% at 3 months after vaccination (6). Studies of the previously available formulation (discontinued in 2003) demonstrated similar efficacy (7). Both the previously and currently available formulations of the vaccine were effective in inducing a vibriocidal antibody response, the best available correlate of protection against cholera infection. No vaccine-related serious adverse events were reported in studies conducted using either of the two formulations. Studies with the currently available vaccine formulation found a slightly higher prevalence of diarrhea (mostly mild) among vaccine recipients (3.8%) than among unvaccinated groups (1.6%) (8). No other differences were detected between vaccinated and unvaccinated groups in the occurrence of any adverse events. Supporting evidence for the Work Group’s findings can be found online (7).

Summary of Quality of Evidence Across Outcomes

The body of evidence, which included studies with the currently available lyophilized CVD 103-HgR formulation and studies with oral toxigenic V. cholerae O1 challenge, consistently indicated high vaccine efficacy and was judged to be GRADE evidence type 1 (evidence from randomized controlled trials or overwhelming evidence from observational studies), which is the strongest type of evidence. For safety outcomes, the data were more limited, because relatively few persons had received the currently available lyophilized vaccine formulation. Few studies evaluated coadministration of CVD 103-HgR with other vaccines or medications (9). Because of these limitations, the GRADE evidence for safety outcomes was judged to be type 3 (evidence from observational studies or randomized controlled trials with notable limitations).


Summary of Rationale for Cholera Vaccine Recommendations

Assessment of the risk for cholera in U.S. travelers was addressed through review of the cholera epidemiology literature and expert judgment. Although cholera is rare among travelers returning to the United States from cholera-affected areas, and cholera is treatable if medical services are readily accessible, certain populations are at higher risk for toxigenic V. cholerae O1 infection and severe outcomes, and a traveler’s risk status is not always clear at the time of consultation.

Risk for Exposure to Toxigenic V. cholerae O1

Persons at higher risk for exposure might include travelers visiting friends and relatives, health care personnel, cholera outbreak response workers, and persons traveling to or living in a cholera-affected area for extended periods (1013). The primary prevention strategy for cholera is consistent access to and exclusive use of safe water and food and frequent handwashing. Nonetheless, travelers to areas of active cholera transmission, which include areas with current or recent endemic or epidemic cholera activity, might be exposed to toxigenic V. cholerae O1 through inadvertent or unexpected means, despite efforts to adhere to prevention measures.

Risk for Poor Outcomes from Cholera

Cholera causes a profuse watery diarrhea leading to dehydration, which can be rapidly fatal unless reversed with fluid replacement therapy. Poor outcomes from toxigenic V. cholerae O1 infection might be more common in travelers with risk factors for severe disease, including the following: persons with blood type O; persons with low gastric acidity from antacid therapy, partial gastrectomy, or other causes; and travelers without ready access to medical services (14,15). Many travelers will not know their blood type at the time of consultation; however, an estimated 45% of persons in the United States have blood type O. Persons with medical conditions that would lead them to tolerate dehydration poorly, such as those with cardiovascular disease or kidney disease, might also be at increased risk for poor outcomes.

Work Group Findings

Through the GRADE systematic review, the Work Group found high-quality evidence that the vaccine is highly effective and lower quality evidence that it is safe. The available safety data indicate no harms except for a slightly elevated risk for mild diarrhea among vaccine recipients. Although cholera is rare, the Work Group concluded that a safe and effective vaccine that can prevent a potentially severe cholera infection can benefit certain travelers.

Recommendations for Prevention of Severe Cholera Among Travelers

Personal Protective Measures

All travelers to cholera-affected areas should follow safe food and water precautions and proper sanitation and personal hygiene measures as primary strategies to prevent cholera. Travelers who develop severe diarrhea should seek prompt medical attention, particularly fluid replacement therapy.

Use of CVD 103-HgR

CVD 103-HgR is recommended for adult travelers (aged 18–64 years) from the United States to an area of active cholera transmission. An area of active cholera transmission is defined as a province, state, or other administrative subdivision within a country with endemic or epidemic cholera caused by toxigenic V. cholerae O1 and includes areas with cholera activity within the last year that are prone to recurrence of cholera epidemics; it does not include areas where only rare imported or sporadic cases have been reported.

The vaccine is not routinely recommended for travelers who are not visiting areas of active cholera transmission. Most travelers from the United States do not visit areas with active cholera transmission (

Booster Doses

At this time, no data exist about the safety and efficacy of booster doses of lyophilized CVD 103-HgR for the prevention of cholera. The duration of protection conferred by the primary dose beyond the evaluated 3-month period is unknown. There is no recommendation for use of booster doses at this time.

Coadministration of Other Medications or Vaccines

Before cholera vaccination. The Vaxchora package insert states that CVD 103-HgR should not be given to patients who have received oral or parenteral antibiotics in the preceding 14 days, because antibiotics might have activity against the vaccine strain. How long a person needs to be off antibiotics before receiving CVD 103-HgR is unknown; the duration will relate to the antimicrobial activity and half-life of the antimicrobial agent or agents. A duration of fewer than 14 days between stopping antibiotics and giving CVD 103-HgR might also be acceptable in certain clinical settings if travel is cannot be avoided before 14 days have elapsed after stopping antibiotics.

During or after cholera vaccination. A study of the previously available formulation of CVD 103-HgR found reduced immunogenicity when coadministered with chloroquine; thus, the manufacturer recommends that if chloroquine is indicated, it be started ≥10 days after CVD 103-HgR vaccination (9).

No data are available on concomitant administration of the currently available formulation of lyophilized CVD 103-HgR with other vaccines, including the enteric-coated oral live-attenuated typhoid vaccine (Ty21a, marketed as Vivotif). Based on expert opinion of how lyophilized CVD 103-HgR buffer might interfere with the enteric-coated Ty21a formulation, taking the first Ty21a dose ≥8 hours after ingestion of lyophilized CVD 103-HgR might decrease potential interference of the vaccine buffer with Ty21a vaccine.

The effect of oral or parenteral antibiotics given after vaccination with CVD 103-HgR is unknown; antibiotics might have activity against the vaccine strain and thus might reduce protection from vaccination. Most (83%) vaccine recipients have vibriocidal antibody seroconversion by 10 days after vaccination (16). Limited evidence suggests that some vaccine recipients who receive antibiotics ≤10 days after vaccination might still have vibriocidal antibody seroconversion (Lisa Danzig, PaxVax, personal communication, January 2017).

Contraindications and Precautions for Use of Lyophilized CVD 103-HgR

Allergy. CVD 103-HgR should not be administered to persons with a history of severe allergic reaction, such as anaphylaxis, to any component of this vaccine or any cholera vaccine.

Age. No data currently exist about the safety and effectiveness of the currently available lyophilized CVD 103-HgR vaccine in children and teens aged <18 years or adults aged ≥65 years.

Pregnancy and breastfeeding. No data exist on use of CVD 103-HgR in pregnant or breastfeeding women. Pregnant women are at increased risk for poor outcomes from cholera infection. Pregnant women and their clinicians should consider the risks associated with traveling to areas of active cholera transmission. The vaccine is not absorbed systemically; thus, maternal exposure to the vaccine is not expected to result in exposure of the fetus or breastfed infant to the vaccine. However, the vaccine strain might be shed in stool for ≥7 days after vaccination, and theoretically, the vaccine strain could be transmitted to an infant during vaginal delivery.

Immunocompromised persons. No data exist on use of the currently available lyophilized CVD 103-HgR formulation in immunocompromised populations. A study of the previously available CVD 103-HgR formulation among HIV-positive adults in Mali found that vibriocidal seroconversion was slightly lower among HIV-positive than HIV-negative participants (58% versus 71%) (17). No significant differences in occurrence of any systemic adverse events were found between vaccinated and comparison populations.

Shedding and transmission. Lyophilized CVD 103-HgR is an oral live attenuated vaccine that can be shed in stool and potentially transmitted to close contacts. The vaccine strain was cultured from stool in 11.1% of vaccine recipients in the 7 days after vaccination with the previously available formulation (16). The currently available formulation of lyophilized CVD 103-HgR was not isolated from the stools of 28 household contacts whose stool was cultured 7 days after vaccination (16), and few (<1%) household contacts of persons vaccinated with the previously available CVD 103-HgR formulation had the vaccine strain isolated from stool cultured 5 days after vaccination. However, later transmission could have been missed. A study with the previously available vaccine formulation detected seroconversion among 3.7% of family contacts of vaccine recipients at 9 or 28 days after vaccination (18).


Reporting of Vaccine Adverse Events and Additional Information

Because surveillance for rare adverse events will add to information about the safety of CVD 103-HgR, all clinically significant adverse events should be reported to the Vaccine Adverse Events Reporting System at or at 1-800-822-7967. To enroll in a registry monitoring pregnancy outcomes in women exposed to lyophilized CVD 103-HgR, contact PaxVax at 1-800-533-5899. Additional information about cholera and CVD 103-HgR is available at


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Suggested citation for this article: Wong KK, Burdette E, Mahon BE, Mintz ED, Ryan ET, Reingold AL. Recommendations of the Advisory Committee on Immunization Practices for Use of Cholera Vaccine. MMWR Morb Mortal Wkly Rep 2017;66:482–485. DOI:

The World Health Organization and Doctors Without Borders reported on an alarming increases in the number of cholera cases in Yemen in the past few weeks.

NY Times

“…..The World Health Organization, the public health arm of the United Nations, reported 2,022 suspected cases of cholera and acute watery diarrhea in Yemen from April 27 to this past Sunday, including at least 34 deaths……”


The number of cholera cases reported by the Ministry of Health in Somalia has reached a cumulative 17 211 cases and 388 deaths with a case fatality rate of 2.25%.


Weekly update: cholera in Somalia, 26 March 2017

26 March 2017 – The number of cholera cases reported by the Ministry of Health in Somalia has reached a cumulative 17 211 cases and 388 deaths with a case fatality rate of 2.25%, which is nearly 4 times as many as were recorded for the same period in 2016, and surpasses the total number of cases recorded in 2016.

While the AWD/ cholera epidemic has been controlled in Hiran, Banadir, Middle Shebelle and Galgadud, most of the recently reported cases were from inaccessible villages in Bay and Gedo regions.

The Ministry of Health and the health cluster led by WHO continue to collaborate with partners and health authorities on response and prevention activities around the country.

In order to address the inaccessibility of cholera treatment centres for people in inaccessible villages in Bay region, the Ministry has deployed doctors and health workers who were trained at Banadir hospital in Mogadishu on case management and surveillance. This is in addition to the 20 health workers already deployed in Bakool and Bay region.

Somalia is at the brink of another famine, after consecutive seasons of poor rainfall and lack of water have killed livestock and crops. This has left around 6.2 out of 12.3 million people in Somalia in need of humanitarian assistance. Nearly 3 million people face food insecurity and nearly 5.5 million people are at risk of contracting water-borne diseases.  Hundreds of thousands of vulnerable people are also on the move in search of food, water, shelter and medical care.

Some of the key needs at present are safe food and water for the affected communities, essential medicines at treatment centres and funds to continue the training and deployment of health workers to the most hard-hit areas.

Haiti: The United Nations’ strategy to fight the cholera epidemic (the “New Approach” )has failed to gain traction. A trust fund created to help finance the strategy has only about $2 million and only 6 of the 193 member states — Britain, Chile, France, India, Liechtenstein and South Korea — have donated.

NY Times

“…..Cholera, a waterborne bacterial scourge that can cause acute diarrhea and fatal dehydration if not treated quickly, has killed nearly 10,000 people and sickened nearly 800,000 in Haiti, the Western Hemisphere’s poorest country, since it was introduced there in 2010 by infected Nepalese members of a United Nations peacekeeping force. This year, as of late February, nearly 2,000 new cases had been reported, amounting to hundreds a week……”



Steven Johnson: How the “ghost map” helped end a killer disease

Steven Johnson

0:11If you haven’t ordered yet, I generally find the rigatoni with the spicy tomato sauce goes best with diseases of the small intestine.


0:23So, sorry — it just feels like I should be doing stand-up up here because of the setting. No, what I want to do is take you back to 1854 in London for the next few minutes, and tell the story — in brief — of this outbreak, which in many ways, I think, helped create the world that we live in today, and particularly the kind of city that we live in today. This period in 1854, in the middle part of the 19th century, in London’s history, is incredibly interesting for a number of reasons. But I think the most important one is thatLondon was this city of 2.5 million people, and it was the largest city on the face of the planet at that point. But it was also the largest city that had ever been built.

1:06And so the Victorians were trying to live through and simultaneously invent a whole new scale of living:this scale of living that we, you know, now call “metropolitan living.” And it was in many ways, at this point in the mid-1850s, a complete disaster. They were basically a city living with a modern kind of industrial metropolis with an Elizabethan public infrastructure. So people, for instance, just to gross you out for a second, had cesspools of human waste in their basement. Like, a foot to two feet deep. And they would just kind of throw the buckets down there and hope that it would somehow go away, and of course it never really would go away. And all of this stuff, basically, had accumulated to the point where the city was incredibly offensive to just walk around in.

1:57It was an amazingly smelly city. Not just because of the cesspools, but also the sheer number of livestock in the city would shock people. Not just the horses, but people had cows in their attics that they would use for milk, that they would hoist up there and keep them in the attic until literally their milk ran out and they died, and then they would drag them off to the bone boilers down the street. So, you would just walk around London at this point and just be overwhelmed with this stench. And what ended up happening is that an entire emerging public health system became convinced that it was the smell that was killing everybody, that was creating these diseases that would wipe through the city every three or four years.And cholera was really the great killer of this period.

2:41It arrived in London in 1832, and every four or five years another epidemic would take 10,000, 20,000 people in London and throughout the U.K. And so the authorities became convinced that this smell was this problem. We had to get rid of the smell. And so, in fact, they concocted a couple of early, you know,founding public-health interventions in the system of the city, one of which was called the “Nuisances Act,” which they got everybody as far as they could to empty out their cesspools and just pour all that waste into the river. Because if we get it out of the streets, it’ll smell much better, and — oh right, we drink from the river. So what ended up happening, actually, is they ended up increasing the outbreaks of cholera because, as we now know, cholera is actually in the water. It’s a waterborne disease, not something that’s in the air. It’s not something you smell or inhale; it’s something you ingest.

3:36And so one of the founding moments of public health in the 19th century effectively poisoned the water supply of London much more effectively than any modern day bioterrorist could have ever dreamed of doing. So this was the state of London in 1854, and in the middle of all this carnage and offensive conditions, and in the midst of all this scientific confusion about what was actually killing people, it was a very talented classic 19th century multi-disciplinarian named John Snow, who was a local doctor in Soho in London, who had been arguing for about four or five years that cholera was, in fact, a waterborne disease, and had basically convinced nobody of this. The public health authorities had largely ignored what he had to say. And he’d made the case in a number of papers and done a number of studies, but nothing had really stuck. And part of — what’s so interesting about this story to me is that in some ways, it’s a great case study in how cultural change happens, how a good idea eventually comes to win out over much worse ideas. And Snow labored for a long time with this great insight that everybody ignored.

4:46And then on one day, August 28th of 1854, a young child, a five-month-old girl whose first name we don’t know, we know her only as Baby Lewis, somehow contracted cholera, came down with cholera at 40 Broad Street. You can’t really see it in this map, but this is the map that becomes the central focus in the second half of my book. It’s in the middle of Soho, in this working class neighborhood, this little girl becomes sick and it turns out that the cesspool, that they still continue to have, despite the Nuisances Act, bordered on an extremely popular water pump, local watering hole that was well known for the best water in all of Soho, that all the residents from Soho and the surrounding neighborhoods would go to.

5:31And so this little girl inadvertently ended up contaminating the water in this popular pump, and one of the most terrifying outbreaks in the history of England erupted about two or three days later. Literally, 10 percent of the neighborhood died in seven days, and much more would have died if people hadn’t fledafter the initial outbreak kicked in. So it was this incredibly terrifying event. You had these scenes of entire families dying over the course of 48 hours of cholera, alone in their one-room apartments, in their little flats. Just an extraordinary, terrifying scene. Snow lived near there, heard about the outbreak, and in this amazing act of courage went directly into the belly of the beast because he thought an outbreak that concentrated could actually potentially end up convincing people that, in fact, the real menace of cholera was in the water supply and not in the air. He suspected an outbreak that concentrated would probably involve a single point source. One single thing that everybody was going to because it didn’t have the traditional slower path of infections that you might expect.

6:42And so he went right in there and started interviewing people. He eventually enlisted the help of this amazing other figure, who’s kind of the other protagonist of the book — this guy, Henry Whitehead, who was a local minister, who was not at all a man of science, but was incredibly socially connected; he knew everybody in the neighborhood. And he managed to track down, Whitehead did, many of the cases of people who had drunk water from the pump, or who hadn’t drunk water from the pump. And eventually Snow made a map of the outbreak. He found increasingly that people who drank from the pump were getting sick. People who hadn’t drunk from the pump were not getting sick. And he thought about representing that as a kind of a table of statistics of people living in different neighborhoods, people who hadn’t, you know, percentages of people who hadn’t, but eventually he hit upon the idea that what he needed was something that you could see. Something that would take in a sense a higher-level view of all this activity that had been happening in the neighborhood.

7:33And so he created this map, which basically ended up representing all the deaths in the neighborhoodsas black bars at each address. And you can see in this map, the pump right at the center of it and you can see that one of the residences down the way had about 15 people dead. And the map is actually a little bit bigger. As you get further and further away from the pump, the deaths begin to grow less and less frequent. And so you can see this something poisonous emanating out of this pump that you could see in a glance. And so, with the help of this map, and with the help of more evangelizing that he did over the next few years and that Whitehead did, eventually, actually, the authorities slowly started to come around. It took much longer than sometimes we like to think in this story, but by 1866, when the next big cholera outbreak came to London, the authorities had been convinced — in part because of this story, in part because of this map — that in fact the water was the problem.

8:30And they had already started building the sewers in London, and they immediately went to this outbreakand they told everybody to start boiling their water. And that was the last time that London has seen a cholera outbreak since. So, part of this story, I think — well, it’s a terrifying story, it’s a very dark story and it’s a story that continues on in many of the developing cities of the world. It’s also a story really that is fundamentally optimistic, which is to say that it’s possible to solve these problems if we listen to reason, if we listen to the kind of wisdom of these kinds of maps, if we listen to people like Snow and Whitehead, if we listen to the locals who understand what’s going on in these kinds of situations. And what it ended up doing is making the idea of large-scale metropolitan living a sustainable one.

9:14When people were looking at 10 percent of their neighborhoods dying in the space of seven days, there was a widespread consensus that this couldn’t go on, that people weren’t meant to live in cities of 2.5 million people. But because of what Snow did, because of this map, because of the whole series of reforms that happened in the wake of this map, we now take for granted that cities have 10 million people, cities like this one are in fact sustainable things. We don’t worry that New York City is going to collapse in on itself quite the way that, you know, Rome did, and be 10 percent of its size in 100 years or 200 years. And so that in a way is the ultimate legacy of this map. It’s a map of deaths that ended up creating a whole new way of life, the life that we’re enjoying here today. Thank you very much.

The secretary general of the United Nations appealed for $825 million in aid to address drought and cholera in Somalia on the brink of famine.  The money was needed to help 5.5 million people, about half of Somalia’s population, survive the next six months.

NY Times

  • 330,000 acutely malnourished children
  • That number that could rise to a million; 3.3 million people in need of medical care to deal with diseases in a country that lacks health infrastructure;
  • 7,731 cases of cholera — 183 fatal — in the past two months.



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