Vibrio cholerae update Dr T V Rao MD

Vibrio cholerae update Dr. T. V. Rao MD 1

Cholera affects Millions • CHOLERA AFFECTS millions, in endemic areas and causes thousands of deaths especially during seasonal epidemics. Robert Koch, the famous microbiologist of Germany, discovered Vibrio cholerae, the causative organism. Because of its characteristic shape he originally referred to it as comma bacilli. Nearly 7 -8 epidemics caused by the pathogen `Vibrio cholerae affected different parts of the world. Dr. T. V. Rao MD 2

Modes of Transmission • Water (infectious dose = 109) • Food (infectious 3 dose = 10 ) • Person-to-person The 19 th-century illustration depicting the spirit of death at a pump was taken from http: //news. nationalgeographic. com/news/2004/06/0614_040614_tvcholera. html Dr. T. V. Rao MD 3

Discovery of Cholera Organisms • Cholera came to Florence in 1854 during the Asiatic Cholera Pandemic of 1846 -63. Pacini became very interested in the disease. Immediately following the death of cholera patients, he performed an autopsy and with his microscope, conducted histological examinations of the intestinal mucosa. During such studies, Pacini first discovered a commashaped bacillus which he described as a Vibrio. Dr. T. V. Rao MD 4

Spread of Cholera Pandemics Dr. T. V. Rao MD 5

Filippo Pacini - 1854 • Filippo Pacini, would gain prominence for his discovery of Vibrio cholera, but not until 82 years after his death, when the international committee on nomenclature in 1965 adopted Vibrio cholerae Pacini 1854 as the correct name of the cholera-causing organism. Until then, many credited Robert Koch (18431910) with this seminal 6 Dr. T. V. Rao MD discovery.

Robert Koch Isolates V. cholrae 1883 • The German physician Robert Koch, like most of the scientific community, was unaware of Pacino's work at the University of Florence. Yet both independently came to a similar conclusion. Since Koch's findings eventually became accepted by his scientific peers, and were widely know in the popular press, he became the acknowledged discoverer of the cholera organism. Dr. T. V. Rao MD 7

Cholerae Outbreaks Dr. T. V. Rao MD 8

Vibrio's in Nature • Vibrio's are among the most common bacteria in surface water worldwide. • They appear curved aerobic rods and are motile, possesing a polar flagellum • V. cholrae serogroups O 1 and O 139 cause cholera in humans, while other vibrio's may cause sepsis or enteritis Dr. T. V. Rao MD 9

Vibrio cholerae Epidemiology and spread of Cholera closely parallels the recognition of V. cholrae transmission in water and the development of sanitary system Dr. T. V. Rao MD 10

Morphology and Identification • V. cholrae is a comma shaped curved rod 2 – 4 µm long’ • It is actively motile by means of polar flagellum. • On prolonged cultivation, vibrio's may become straight rods that resemble the gramnegative enteric bacteria. Dr. T. V. Rao MD 11

Vibrio Cholerae Vibrio spp. V. cholerae Non-O 1 Other vibrios V. cholerae O 1 Biotype Classical El Tor Serotype Ogawa Inaba Toxin Toxigenic Non-toxigenic Dr. T. V. Rao MD 12

Vibrio cholerae O 1 • Salt resistant • Heat and acid sensitive • El Tor biotype – Asymptomatic infections common • 75% asymptomatic • 18% mild diarrhea • 1 -5% severe-cholera gravis – Fast growing in food – Lengthy survival in environment Dr. T. V. Rao MD 13

Vibrio cholerae O 1 • Infectious dose: 106 – 108 – Varies with vehicle of transmission – Gastric acidity • Incubation period – 1 -3 days (½-5 days) Dr. T. V. Rao MD 14

Transmission-worldwide • Contaminated water • Contaminated food – Raw or undercooked seafood – Rice, cereals, gruels left at ambient temperature • Person to person transmission not common • Fecal-oral transmission is possible Dr. T. V. Rao MD 15

Known Virulence Factors n n Integrons Toxins • • n CT HA Protease RTX Toxin ACE and Zot Adherence/Adhesins • • Accessory Colonization Factors (ACF) Omp. U & other Omp Proteins - outer membrane proteins • Mannose-fucose-resistant cell hemagglutinin & Mannose sensitivev hemagglutinin (Faruque, 2002) from: http: //www. amnh. org/nationalcenter/infection/01_mic/01 a_bac. html Dr. T. V. Rao 16 • Toxin. Image Co-regulated Pilus MD (TCP)

Enrichment Medium • Enrichment of the fecal specimens are done on Alkaline peptone water • Venkataraman Ramakrishan Meidum is simple medium can be used as transport medium Dr. T. V. Rao MD 17

Culture • V. cholrae produces convex, smooth, round colonies that are opaque and granular in transmitted light; • Grow well at 370 c on many defined media. • Vibrio's grow at a very high p. H ( 8 -5 – 9 -5 ) and are rapidly killed by acid • In resource poor laboratories Mac. Conkey agar can be used. Dr. T. V. Rao MD 18

Selective Medium - TCBS • V. cholrae grows well on Thiosulphate citrate bile sucrose (TCBS ) agar, on which it produces yellow colonies that are readily visible against the dark green background of the agar. Dr. T. V. Rao MD 19

Growth Characteristics • V. cholerae ferments sucrose and mannose but not arabinose • A positive Oxidase test is key step in preliminary identification of V. cholerae and other Vibrio's • Vibrio species are susceptible to compound 0/129 and differentiates from Aeromonas • Vibrio's usually grow on medium containing 6% Nacl • Halophilic vibrios need and grow in the presence of > 6% Nacl • On Blood agar Vibrios show hemodigesion Dr. T. V. Rao MD 20

Antigenic Structure and Biological Classification • Many Vibrio's share a single healable H antigen. Antibodies to H antigen are probably not involved in the protection of susceptible hosts. • V. cholrae has O lipopolysaccharide that confer serologic specificity • There at least 139 O antigen groups • V. cholrae strains of O group 1 and O group 139 cause classic cholera. • Occasionally non 01/non 0139 V. cholrae cause Cholera like disease Dr. T. V. Rao MD 21

V. cholrae - typing • V. cholrae 01 has determinants that make possible futher typing • Serotypes are Ogawa, Inaba and Hikojima. Epidemic V. cholerae is biotyped into 1 Classic 2 El Tor Dr. T. V. Rao MD 22

El Tor Vibrio's • The El Tor vibrios produce a Hemolysin and positive results with Voges- Proskauer test • Resistant to Polymyxin B • Molecular techniques can also be used to type V. cholrae • Tests can be done reference laboratories and technically demanding Dr. T. V. Rao MD 23

New Epidemic of V. cholrae 0139 • The epidemic of cholera caused by V cholerae 0139 has affected at least 1 1 countries in southern Asia. V cholerae 0139 produces severe watery diarrhea and dehydration that is indistinguishable from the illness caused by V cholerae 01, and appears to be closely related to V cholerae 01 biotype El Tor strains. Specific totals for numbers of V cholerae 0139 cases are unknown because affected countries do not report infections caused by 01 and 0139 separately; however, >100, 000 cases of cholera caused by V cholerae 0139 may have occurred. Dr. T. V. Rao MD 24

V. cholrae- 0 -139 • V. cholrae 0139 is very similar to V. cholrae 01 El Tor biotype • V. cholrae 0139 do not produce 01 type lipopolysaccharide and does not have all the genes necessary to make this antigen • V. cholrae 0139 make a polysaccharide capsule like other non 01 V. cholrae strains while V. cholrae 01 does not make a capsule Dr. T. V. Rao MD 25

V. cholrae 0139 Dr. T. V. Rao MD 26

V. cholrae 0139 Epidemic The epidemic of cholera caused by V cholerae 0139 has affected at least 1 1 countries in southern Asia. V cholerae 0139 produces severe watery diarrhoea and dehydration that is indistinguishable from the illness caused by V cholerae 01 and appears to be closely related to V cholerae 01 biotype El Tor strains. Dr. T. V. Rao MD 27

Vibrio cholerae - Enterotoxin • V. cholrae produce heat labile enterotoxin with a Moll wt. of about 84, 000 consisting of sub units A ( MW 28, 000 ) and B • Ganglioside GM 1 serves as a mucosal receptor for subunit B, which promotes entry of subunit A into the cell • Activation of subunit A 1 yields increased levels of intracellular c. AMP and results in prolonged hyper secretion of water and electrolytes • There is increased sodium dependent chloride secretion, and absorption of sodium and chloride is inhibited • The genes for V. cholrae Enterotoxin are on the bacterial chromosome • Cholerae Enterotoxin is antigenically related to LT of Escherichia Dr. T. V. Rao MD 28

Mechanism of Action of Cholera Toxin Dr. T. V. Rao MD 29 REVIEW

Mechanism of Action of Cholera Toxin NOTE: In step #4, uptake of Na+ and Clfrom the lumen is also blocked. HCO 3 - = bicarbonate which provides buffering capacity. 1 2 3 4 Dr. T. V. Rao MD 30

Pathology and pathogenesis • V. cholrae is pathogenic to humans. • When bacteria are consumed with food few organism as much as 102 – 104 organisms are adequate to cause an attack because of the buffering capacity of the food • Any medication or conditions that decreases stomach acidity makes a person more susceptible to infection with V. cholrae • But a person with normal gastric acidity has to consume 1010 or more V. cholrae are when ingested with water Dr. T. V. Rao MD 31

Clinical events in Cholera Dr. T. V. Rao MD 32

Pathology • Cholera is not an invasive infection • Organisms do not reach blood, only act locally • Virulent V. cholrae organism attach to the microvillus of the brush border of epithelial cells • They multiply and liberate cholera toxin and perhaps Mucinase and Endotoxin. Dr. T. V. Rao MD 33

Clinical manifestations • Diarrhea occurs as much as 20 – 30 Liters/Day fluids are lost. • Results in dehydration • Shock • Acidosis • Can lead to death. • About 60% of infections are caused with classic V. cholrae and are asymptomatic, about 75% of infections are caused by Dr. T. V. Rao MD El Tor biotype 34

Clinical features • The incubation period is 1 – 4 days for person who develop symptoms, depends on the size of the inoculums ingested • Manifest with Nausea , vomiting, profuse diarrhea, and abdominal cramps Rice water stool characteristic of cholera loss of fluid leads to profound dehydration Circulatory collapse and anuria. Dr. T. V. Rao MD 35

Presentation- Rice water diarrheal Dr. T. V. Rao MD 36

Stool Examination • Stool specimen appear as Rice water • On Microscopy contain Mucus, epithelial cells and large number of Vibrio's. • Milder cases difficult to differentiate from other diarrheal diseases. • El Tor vibrio's cause milder disease than classic biotypes. Dr. T. V. Rao MD 37

Specimen Collections • Stool specimens are collected in acute stage of the disease. before the antibiotics are administered. • Simple collection of stool in a wide Mouthed container is safe and hygienic. • Specimens should not be collected from bed pans. • Vomitus not advised. Dr. T. V. Rao MD 38

Diagnosis • Stool culture: Toxigenic Vibrio cholerae O 1 • Use Cary Blair Transport media if available – Viable for many days at room temperature • • Use TCBS media for culture Use V. cholerae serogroup O 1 antisera Confirm presence of cholera toxin Cholera Rapid Test Dipsticks Dr. T. V. Rao MD 39

Laboratory Diagnosis • Mucus flecks from stool are cultured. • Smears are not useful for diagnosis. • Dark field microscopy shows rapidly motile vibrio's. Dr. T. V. Rao MD 40

Laboratory Diagnosis Culture • Growth is rapid on Blood agar, • On TCBS medium typical colonies can be picked in 18 hours. • The stool specimens can be transported in Venkataraman Ramakrishnan medium • Alkaline peptone water is ideal enrichment medium Dr. T. V. Rao MD 41

Bio Chemical Reactions V. cholrae( Hemolysis V. cholrae (El Tor) Classical ) -ve Voges -proskauer test -ve Polymyxin sensitivity +ve Group IV phage Susceptibility +ve Chick erythrocyte Agglutination -ve +ve -ve +ve Dr. T. V. Rao MD 42

Confirmatory Tests for V. cholrae • V. cholrae organisms are further identified by slide agglutination tests using anti -0 group 1 or group 139 Antisera and by Biochemical reactions Dr. T. V. Rao MD 43

Immunity in Cholerae • Gastric acid produces some protection against cholera vibrios. • An attack of cholera if followed by immunity to reinfection but the duration and degree of immunity are not known. • In experimental animals specific Ig. A antibodies occur in the lumen of intestine • Vibriocidal antibodies in the serum titer > 1: 20 have been associated with protection against colonization and disease • The presence of antitoxin antibodies have not been asociated with protection Dr. T. V. Rao MD 44

When you suspect Cholera • The diagnosis of cholera should be considered in patients with watery diarrheal who have recently (i. e. , within 7 days) returned from cholera -affected countries. Patients with suspected cholera should be reported immediately to local and state health departments. Dr. T. V. Rao MD 45

Treatment • Treat all cases / suspect cases promptly • Assess degree of dehydration • Determine if rehydration should be oral or IV • Don’t wait for laboratory confirmation to treat • Death rates from severe cholera can be decreased from ~50% to <1% Dr. T. V. Rao MD 46

Treatment • The most important part of therapy consists of correction water and electrolyte imbalance to correct severe dehydration and salt depletion. • Oral Tetracycline tends to reduce stool output in cholera and shortens the period of excretion of vibrio's • In some endemic areas tetracycline resistance has emerged the genes are carried by transmissible plasmids Dr. T. V. Rao MD 47

Vaccines for Cholera • The licensed parenteral cholera vaccine provides only limited and brief protection against V cholerae 01, may not provide any protection against V cholerae 0139, and has a high cost-benefit ratio; therefore, the vaccine is not recommended for travellers. New oral cholera vaccines are being developed. Dr. T. V. Rao MD 48

Newer Vaccines • New oral cholera vaccines are being developed and provide more reliable protection, although still at a high cost per case averted. None of these vaccines have attained the combination of high efficacy, long duration of protection, simplicity of administration, and low cost necessary to make mass vaccination feasible in choleraaffected countries. Dr. T. V. Rao MD 49

CDC – On Vaccination for Cholerae Cholera vaccine is no longer required, nor recommended for the vast majority of travellers by the Centres for Disease Control and Prevention (CDC). Dr. T. V. Rao MD 50

Epidemiology of Cholerae • Six Pandemics of Cholera occurred between 1817 – 1923. • Most likely V. cholrae 01 of Classical type contributed to pandemics. • All pandemics originated in Indian continent. • The seventh pandemic originated in Celebes Islands in Indonesia on 1961. • Spread far and wide Dr. T. V. Rao MD 51

th 8 Pandemic ? Spread of 0 -139 • Several identify that onset of 0 -139 is considered as 8 th pandemic started in India. • Cholerae is spread by contact with persons in early or even mild illness. • By contaminated water, food, flies • Only 1 -5% of exposed will get effected • Carrier stage seldom exceeds 3 - 4 weeks. Dr. T. V. Rao MD 52

Control of Cholerae • Needs improvement of Sanitation associated with water treatment and food. • Patients infected preferably isolated. • Excreta disinfected • All contacts to be followed up Dr. T. V. Rao MD 53

Use of Vaccine and Chemoprophylaxis • Chemoprophylaxis with antibiotics is effective. • Repated injection of vaccine containing either Lipopolysaccharides extracted from Vibrio's or dense Vibrio's suspension can offer limited prevention to heavily exposed persons. • Vaccines not useful in Epidemic controls Dr. T. V. Rao MD 54

Prevention of Cholera • Although cholera can be life-threatening, it is easily prevented and treated. In the United States, because of advanced water and sanitation systems, cholera is not a major threat; however, everyone, especially travellers, should be aware of how the disease is transmitted and what can be done to prevent it. • Several regions in the Developing countries continue to be endemic locations. Dr. T. V. Rao MD 55

Cholera vaccines and vaccination • Two types of oral cholera vaccines are available: (i) Dukoral and (ii) Shanchol and m. ORCVAX. The latter two are identical vaccines in terms of strains but formulated by different manufacturers using different methods Dr. T. V. Rao MD 56

Characteristics of Dukoral, Shanchol and m. ORCVAX • The available oral cholera vaccines are safe 29 and provide sustained protection of >50% that lasts for 2 years in endemic populations. 30 Shanchol and m. ORCVAX have demonstrated longer term protection in children aged <5 years and do not require booster doses every 6 months. Dr. T. V. Rao MD 57

Potential use of oral cholera vaccines • Use of oral cholera vaccines in emergency situations is accepted but remains a challenge. To date, there is no specific indication for use of oral cholera vaccines in endemic situations, and intervention studies are being performed to prove their effectiveness as a public health tool. Dr. T. V. Rao MD 58

Other Bacteria resembling Vibrio cholerae Dr. T. V. Rao MD 59

Characteristics of Aeromonas and Plesiomonas Gastroenteritis Dr. T. V. Rao MD 60 REVIEW

Virulence Factors Associated with Non-cholerae Vibrio's (Kanagawa positive) Dr. T. V. Rao MD 61 REVIEW

Characteristics of Aeromonas and Plesiomonas Gastroenteritis Epidemiological Features Natural Habitat Source of Infection Aero monas Plesiomonas Fresh or brackish water Contaminated water or food Present Present Absent Present Clinical Features Diarrhea Vomiting Abdominal Cramps Fever Blood/WBCs in Stool Dr. T. V. Rao MD 62

Wish to Know More About Cholerae Dr. T. V. Rao MD 63

• Programme created by Dr. T. V. Rao MD for Medical and Health care workers in the Developing World • Email • doctortvrao@gmail. com Dr. T. V. Rao MD 64

Reference: www. Slideshare. com Dr. T. V. Rao MD 65