cholera

from Wikipedia, the free encyclopedia
Classification according to ICD-10
A00.0 Cholera due to Vibrio cholerae O: 1, Biovar cholerae
A00.1 Cholera due to Vibrio cholerae O: 1, Biovar eltor
A00.9 Cholera, unspecified
ICD-10 online (WHO version 2019)
Cholera Spread in the World (2004)

Cholera ("bile flow", term for 'diarrheal disease', from Greek χολή cholḗ 'bile'), also Cholera asiatica ( Asian cholera ), biliary diarrhea (formerly also bile dysentery ), is a serious bacterial infectious disease predominantly of the small intestine caused by the bacterium Vibrio cholerae is caused. The infection usually takes place via contaminated drinking water or infected food. The bacteria can cause extreme diarrhea (with "rice water stools") and severe vomiting (vomiting diarrhea), which can lead to desiccosis due to electrolyte loss with low temperature and collapse. Although most infections (around 85%) are symptom -free, the mortality rate if the disease breaks out is between 20 and 70% if left untreated.

Cholera endemic in East Asia ("Cholera asiatica", "Asian cholera") probably occurred on the Indian subcontinent over several centuries (starting from the Ganges Delta ) in the form of locally limited epidemics, but was unknown on other continents. The first pandemic occurred in the period from 1817 to 1824 and affected parts of Asia , East Africa and Asia Minor, and subsequently Russia and Europe. The first illnesses in Germany occurred in 1831. The proof provided by the doctor John Snow in 1855 that a cholera epidemic in the London borough of Soho was related to contaminated drinking water is considered to be the birth of modern epidemiology . The cholera epidemic of 1892 , in which there were many deaths in Hamburg, is considered to be one of the last serious cholera epidemics on the European continent. The cholera epidemic in Yemen since 2017 is considered to be the worst cholera epidemic in history, with over one million illnesses and more than 2,300 deaths.

Vibrio cholerae , the causative agent of cholera, was described - unnoticed by the public - by Filippo Pacini in 1854 and discovered in 1883 by Robert Koch in the intestines of people who died of cholera. Koch was able to prove that the pathogen he called “comma bacteria” is excreted by germ carriers and can spread further in water. Also in 1854 the Catalan Joaquim Balcells i Pascual described the pathogen and in 1856 probably the two Portuguese António Augusto da Costa Simões and José Ferreira de Macedo Pinto .

The disease can occur epidemically and is notifiable in Germany and Austria ; The following must be reported by name: the suspected illness, the illness, the death, in Germany also the evidence of the pathogen. In Switzerland, sick, infected and exposed persons must be reported in an identifiable manner.

Pathogen

Cholera bacteria in the electron microscope
Cholera bacterium O395 wt Wild Type in the electron microscope

Cholera is caused by the bacterial species Vibrio cholerae , whose exotoxin (the cholera toxin ) leads to severe, rice-water-like diarrhea (almost liquid like water with a cloudy white color) with great loss of fluid.

The pathogen was first described by Filippo Pacini in 1854 as a curved, comma-shaped and highly mobile bacterium. John Snow also recognized in 1854 that the prevailing cholera in London was not spread by vapors ( miasms ), as was generally assumed at the time. Robert Koch , together with Bernhard Fischer and Georg Gaffky, cultivated the pathogen from the intestines of deceased patients in India in 1884 .

Recent findings also showed that the ultimately disease-causing ( pathogenic ) cholera toxin by a DNA section of the Vibrio cholerae expressing is originally from a bacteriophage derived.

Occurrence

Cholera occurs frequently in countries in which drinking water and sewage systems are not separated from one another and therefore the drinking water is often contaminated with cholera pathogens. These pathogens are mainly found in faeces as well as in river and sea ​​water into which faeces are discharged. In addition, fish and other food from rivers and the sea can be contaminated with cholera pathogens.

In industrialized countries , waterworks and sewage treatment plants ensure that the population is adequately supplied with hygienically safe drinking water, so that cases of cholera are rare.

The cholera infection

transmission

Cholera bacteria enter the human gastrointestinal tract primarily via drinking water contaminated with faeces and less via foodstuffs or everyday objects contaminated with pathogens . A direct transmission from person to person is considered possible, but is considered a rather rare event.

Symptoms and ailments

Typical "rice water chair" for cholera
A person suffering from cholera with clear signs of dehydration

An infection with the pathogen leads to the outbreak of the disease in only about 15 percent of cases - after an incubation period of 2 to 3 days.

Cholera then usually has three stages:

  1. Stage with vomiting diarrhea with often thin stool, often with flakes of mucus ("rice water stool ") and rarely with pain in the stomach .
  2. Stage of lack of fluids ( desiccosis ). This leads to a low temperature and a noticeable facial expression with a pointed nose, sunken cheeks and standing skin folds.
  3. Stage of general body reaction with drowsiness, confusion , coma and rash . Complications such as pneumonia , inflammation of the parotid gland and sepsis can also occur.

People with blood group 0 appear particularly at risk, those with blood group AB the least.

diagnosis

For diagnosis lead the typical symptoms that occur when a person in an area with known cholera risk. Acute microscopy and stool culture are performed. The cultivation takes place with the selective medium Thiosulfate-Citrate-Bile-Sucrose-Agar (TCBS) . In addition, stool samples can be inoculated in alkaline peptone water (APW) at pH 8.4 overnight . After an incubation time of 4 to 8 hours at 20 to 40 ° C (ideally 37 ° C), the inoculate is spread onto TCBS. A definitive laboratory diagnosis is made with the help of antiserum . Additional methods are listed under Evidence of Vibrio cholerae .

treatment

The most important treatment measure is the adequate replacement of fluids, sugar and salts. This replacement is best done intravenously because it bypasses the inflamed gastrointestinal tract. In countries of the third world , however, oral fluid replacement ( WHO drinking solution ) is also practiced easily and successfully: The WHO recommends an orally administered salt and glucose solution in water .

Components
Glucose ( grape sugar ) 13.5 g / l
Sodium citrate 2.9 g / l
Sodium chloride (table salt) 2.6 g / l
Potassium chloride 1.5 g / l

The optimal mixture contains the Oral Rehydratation Solution , which is available as a ready-made powder.

The WHO recommends the administration of antibiotics only in severe forms of cholera. Children under the age of 12 should receive erythromycin for three days , 12.5 mg / kg four times a day. Children under 5 years of age should also receive 20 mg of zinc for ten days, or 10 mg for children under 6 months of age. For people over 12 years of age, 12.5 mg / kg tetracycline or a single dose of 300 mg doxycycline should be administered four times daily for three days . However, antibiotic resistance should be determined, as resistant strains have been described in all regions. Partly also be quinolone antibiotics such as ciprofloxacin and in children trimethoprim - sulfamethoxazole or in children and pregnant women azithromycin used.

prevention

As a preventive measure, compliance with high hygienic standards is recommended , above all the provision of hygienically perfect drinking water . A particularly simple, but so far little known, way of disinfecting drinking water is to use a PET bottle to expose water of different origins to sunlight. This method, also known as SODIS , is recognized for its effectiveness by the World Health Organization (WHO). Even water filters made of folded material (e.g. an old saree) reduce the risk of illness by almost half, as researchers from the National Science Foundation headed by Rita R. Colwell in Bangladesh found.

The previous intramuscular vaccination is to be judged as outdated and ineffective. More recent developments ( oral vaccination ) are more effective and better tolerated and also protect to a certain extent against classic traveler's diarrhea . In 2013, the Robert Koch Institute referred to the information provided by the WHO, according to which vaccination is not generally recommended, but may be appropriate for people who are involved in relief operations in epidemic areas. For a vaccination against cholera, a dead vaccine (inactivated cells of Vibrio cholerae ) is used, which is administered orally . This oral cholera vaccine ( OCV ) has been used in a vaccination program in some areas of Haiti since 2012. A new, also orally administered cholera vaccine is not only antibacterial (against the pathogen), but also antitoxic (against the cholera toxin).

Reporting requirement

In Germany, cholera is a reportable disease according to Section 6 (1) of the Infection Protection Act . You are required to report by name in the event of suspicion, illness or death. The diagnosing doctors, etc., are obliged to report the illness ( Section 8 IfSG).

In Austria, cholera is also a notifiable disease in accordance with Section 1 (1) of the 1950 Epidemic Act . The reporting obligation relates to suspected cases, illnesses and deaths. Doctors and laboratories, among others, are obliged to report this ( Section 3 Epidemics Act).

In Switzerland, cholera also for doctors, hospitals, etc. a notifiable disease and that after the Epidemics Act (EpG) in connection with the epidemic Regulation and Annex 1 of the Regulation of EDI on the reporting of observations of communicable diseases of man . A positive laboratory analysis result is subject to reporting.

Research history

Robert Koch (third from right) on his cholera research expedition to Egypt in 1884, a year after he identified V. cholerae .

Since the late Middle Ages there had been two theories about the spread of epidemics: the miasm theory (transmission through foul vapors) and the contagion theory (transmission through touching a sick person). The empirical findings from the first cholera epidemics were initially devastating for medicine because they refuted both theories. For half a century there was no new theory.

In 1832, under the direction of Edwin Chadwick , in response to the first cases of cholera in London, orders were issued to flush sewage and silt from the foul-smelling sewers into the Thames . Since the companies that supplied London with drinking water but took it from the Thames, the measure led to the contamination of the drinking water and an epidemic with 14,000 deaths. There were other major cholera epidemics in the mainland and Great Britain in the mid-19th century.

Joseph Griffiths Swayne , Frederick Brittan and William Budd (1811–1880) examined sewage and found comma-shaped microorganisms. In 1849, English doctors John Snow and William Budd presented a paper in which they believed that cholera was caused by living organisms in drinking water. However, this hypothesis was slow to gain acceptance.

Map of the cholera outbreak in Soho, London in 1854 by Dr. Snow.

In 1854 Filippo Pacini described the comma-shaped bacterium Vibrio cholerae as the causative agent of cholera. He was not alone in his assumption that a microorganism was the cause of cholera. In 1854 John Snow re-examined the transmission of cholera through polluted drinking water. In the same year, together with Arthur Hill Hassall , he reported to the Medical Council of the General Board of Health in London that the Pacini hypothesis was a serious consideration, as “myriads of vibrions” were teeming with the characteristic rice-water-like excretions of the sick.

In 1855, Snow showed in his "East" study that the severe cholera epidemic of late summer 1854 in the London borough of Soho was caused by contaminated drinking water from a pump system on Broad Street. At the request of John Snow, Hassall examined the water from the pump system and the Thames and the stool samples from the patients and found cholera pathogens in all cases. Then, due to the return of the epidemic, the construction of the great London sewage network under Joseph Bazalgette became important . The measures against cholera were announced in “cholera newspapers”. They also contained long lists of names of those suffering from cholera and those who had died.

Pacini's hypothesis that cholera would be caused by microorganisms that could finally after the discovery of the infection mechanism by Robert Koch , together with Bernhard Fischer and Georg Gaffky be proved. In Calcutta in January 1884 they cultivated the pathogen from the intestines of deceased patients in pure culture. It was only in 1959 that Sambhu Nath De discovered that an enterotoxin is the cause of cholera .

Cholera Pandemics

A disease that, according to current knowledge, may have been cholera, had been around since around 600 BC. Observed in the Gangestal in India . It is assumed that the pathogen was permanently present in some watercourses, but appeared periodically over a long period of time in a comparatively mild and locally limited form.

1817 to 1923

Apart from epidemics (regionally limited spread of the disease), six pandemics (spread across countries and continents ) can be distinguished since 1817 :

Cholera barracks in Hamburg during the epidemic of 1892
Disinfection column with chlorinated lime carts during the cholera epidemic in Hamburg in 1892
  • 1. Pandemic (1817–1824): Parts of Asia are affected, also East Africa, from 1823 Asia Minor and subsequently Russia and Europe. Philip Alcabes puts the first pandemic, which occurred in the period from 1817 to 1824, in connection with the upheavals on the Indian subcontinent as a result of the British East India Company's gain in influence. Famines and armed conflicts led to greater migration movements within the continent and, due to the associated deteriorating living conditions of the Indian population, created the prerequisite for the disease to initially spread widely on the Indian subcontinent and from there to Western Europe and Russia. Gillen D'Arcy Wood sees the drastic climate change in the years 1815–1818, which was caused by the eruption of Tambora , a volcano on Sumbawa , Indonesia , as the main prerequisite for the spread .
It is not entirely clear which route the pathogen took from India to other regions of the world. Since the pathogen can survive in water containers for several days, it is very likely that the pathogen was spread further via trade routes. Between 1820 and 1822 the pathogen reached the Arabian peninsula via ship connections and Afghanistan and Persia via caravan routes. The outbreak in Muscat in 1821 dates back to British troop movements who came into contact with the pathogen in either India or Afghanistan. From Muscat the pathogen spread along the trade routes of the Arab slave trade to northeast Africa.
  • 2. Pandemic (1826–1841): The epidemic spreads from Mecca to Egypt and Europe. Around 1830, the Russian troops, who had gathered against the Polish November uprising, first brought the disease from the Indian border to Europe and a little later to North America. Cholera broke out in the Baltic coastal areas and Warsaw from 1830. From there the pathogen reached Great Britain, Germany and Austria (1831), France (1832), the Netherlands (1832) and the USA (1832). The cholera deaths include Hegel , Clausewitz , Gneisenau , Diebitsch , Langeron , Perier , Georges Cuvier and others. v. a. However, it was mainly the low-income sections of the population who were affected. In July 1832, dozens of New York residents were dying every day. 95 percent of these fatalities were buried in poor graves . Within a few years almost all European countries were hit by devastating epidemics. In Vienna, cholera claimed around 2,000 deaths from 1830 to December 1831. The cause was on the one hand the enormous growth of the city, with which the Viennese water supply could not keep up, on the other hand the Danube flood in 1830 , which flooded many cesspools and thus contaminated the groundwater .
Memorial cross for the victims of cholera in 1854 in the cemetery in Munich-Haidhausen
  • 3. Pandemic (1852–1860): The epidemic affects part of Asia, the Maghreb (especially Algeria) and Europe. There were more than a million deaths in Russia. In the Crimean War (1853–1856), more soldiers on both sides were killed by cholera than in combat. So died u. a. the British Commander-in-Chief Lord Raglan and the Commander-in-Chief of the French Fleet, Armand Joseph Bruat , from the disease. In 1854 the epidemic broke out in London and parts of southern Germany (including Munich). In Vienna in 1854, the poet Ferdinand Sauter was the first victim of another outbreak after the cholera epidemic in 1830/1831.
  • 4. Pandemic (1863–1876): Across Northern Europe, to Belgium in 1866, then France and finally North Africa and South America. During the Austro-Prussian War (1866) the epidemic broke out in the Prussian army and killed 3,139 soldiers. With the advance of the troops, cholera spread in Lower Austria . On July 27, 1866, another case of cholera was discovered in Vienna. On August 24, 1866, an epidemic began there that caused deaths in the city by November 23 of the same year, 1869. There were around 4,000 victims in the area. In the rest of Lower Austria, an estimated 23,000 cases of cholera occurred in 490 localities; about 8,000 people died. - This wave of cholera also hit cities and regions in Germany that were previously less affected. The disease spread in Saxony and Thuringia in 1865/66; In Erfurt almost 1000 people died, in Apolda 200 and for the first time also in Weimar around 70. - In the years 1855 and 1867 in the city ​​of Zurich around 500 people died of cholera as a result of precarious hygienic conditions in many apartments. In the Swiss municipality of Binningen alone, 26 of the then 1200 inhabitants died within two months in 1855, according to the report by the local pastor Jonas Breitenstein .
  • 5. Pandemic (1883–1896): The epidemic spreads from India to the east and west to several continents. By 1892 cholera was rampant in Afghanistan and reached Russia . There was one last major epidemic in Hamburg this year. During the cholera epidemic of 1892 , Robert Koch suspected that Russian emigrants from America had brought them with them to the German port city. However, there are also doubts about this hypothesis as the first cholera cases were diagnosed among locals. The outbreak of the pathogen was favored by the lack of education of the population and too few sewage treatment plants. More than 8,600 people died in Hamburg alone.
  • 6th pandemic (1899–1923) : Coming from Asia, the 6th pandemic reached Russia and then spread to Central and Western Europe.

In addition to these pandemics, there have been serious local epidemics. Berlin alone was ravaged by cholera thirteen times in 42 years between 1831 and 1873. In all of Prussia the epidemics of 1848/49, 1852, 1855 and 1866 were particularly severe; in the latter, 114,683 people officially died of cholera. Germany was last hit by cholera in 1873. In southern Germany, Munich in particular suffered badly. A cholera outbreak in London in 1848/1849 was far more serious than the cholera outbreak in 1832/1832. During this outbreak, 15,000 people died in London, more than 0.5 percent of what was then an urban population of around 2.5 million. In the first week of September 1849, 300 people died a day.

The 7th pandemic since 1961

The WHO speaks of the outbreaks that have occurred since 1961, some in the form of epidemics, of the 7th pandemic. It is the longest currently (as of February 2019) rampant pandemic. From Indonesia, the epidemic made its way to the Soviet Union and then to Central and Western Europe. The trigger is the El Tor subtype of Vibrio cholerae .

The last major epidemic of the 20th century spread in Peru in 1991. On February 9, the Peruvian government declared a national emergency , but the epidemic also occurred in Ecuador , Colombia , Mexico and Nicaragua . Of the around 400,000 people who fell ill in South America at the time , around 12,000 died.

A cholera epidemic triggered during the Rwanda War claimed around 40,000 victims in 1994.

In 2007, a cholera epidemic spread across much of Iraq, affecting around 4,700 people. In 2007, 177,963 cases of cholera were reported worldwide; the share of fatal courses of all cholera cases reported to the WHO was 2.3%.

The cholera epidemic in southern Africa 2008/2009:
  • Deaths
  • Infections

    • At the beginning of December 2008, a national emergency was declared in Zimbabwe as a result of a severe cholera epidemic, as the country was no longer able to take care of the 18,000 suspected cases itself. The epidemic spread to the neighboring border area Vhembe of South Africa , where more than 500 diseases have been registered. It was declared a disaster area on December 11, 2008. Just one day later, Zimbabwean President Mugabe declared the cholera epidemic in his country over, although at the time, according to the independent aid organization Oxfam , at least 60,000 people were still suffering from the disease. According to the United Nations, since the outbreak of the epidemic in August 2008, almost 98,000 people in Zimbabwe have contracted cholera and over 4,200 have died (as of May 7, 2009).

    At the end of October 2010, Haiti declared a sanitary emergency following the outbreak of cholera. The infections initially occurred in the rural Artibonite province , north of the capital Port-au-Prince . On November 9, 2010, cholera diseases were reported in the capital for the first time. At that time, more than 550 people had died from the disease and more than 8,000 Haitians were infected. At the beginning of 2010 a severe earthquake hit the region. After the disaster, more than 500,000 people fell ill with cholera and over 7,000 died. The situation has worsened again since the start of the rainy season in 2012. According to MSF data , the number of patients has more than tripled in less than a month. The reason for this was a bacterium that was introduced by Nepalese UN soldiers.

    Between May 30 and June 6, 2011, Ukraine reported 14 cases of cholera to WHO.

    On July 2, 2012, 53 cases of cholera and three deaths were reported from Manzanillo, eastern Cuban . On August 28, the Cuban Ministry of Health declared the cholera outbreak over. As a result, there were a total of 417 confirmed cases. In addition to the province of Granma , where a large part of the diseases were registered, there were also isolated cases in the provinces of Santiago de Cuba , Guantánamo and in the capital Havana . However, it remained with the three deaths. However, according to unofficial reports, at least 15 people were killed in Granma Province alone. Just a month after the epidemic was declared over, authorities announced nine new cases of cholera in Granma province. As a result of Hurricane Sandy , there was another sharp increase in new infections, according to reports that have not been officially confirmed. The focus of the epidemic this time was the provinces of Santiago de Cuba and Guantánamo as well as individual cases in the province of Holguín . In January 2013, the Cuban authorities had to admit 51 cases in Havana after independent sources had reported them for a long time and assumed a far higher number of those affected.

    In August 2012 the government of Sierra Leone declared a national emergency because of a cholera epidemic. According to the Foreign Office in Berlin, there were over 10,000 sick people and several hundred dead. In the capital Freetown and the surrounding area, 176 people are said to have died of the disease since the beginning of the year.

    From September 2013 cholera also appeared in Mexico . As of mid-October, 171 cases had been recorded, 157 of them in the state of Hidalgo . A victim died. According to the WHO, the cholera pathogen is 95% similar to the variants found in Haiti, the Dominican Republic and Cuba.

    Cholera in Yemen: Graphic representation of the diseases per 10,000 inhabitants in the individual governorates since April 24, 2017, as of April 30, 2019

    The first cholera outbreak occurred in Yemen in September and October 2016. As of April 24, 2017, there was a rapid increase in Yemen by more than 23,000 new cases of suspected cholera, according to a report by the WHO . At the end of June 2017, according to the WHO, 200,000 people were infected and more than a thousand people had died of the infectious disease. At the beginning of November 2017, 900,000 people were infected in Yemen. In December 2017, according to the International Committee of the Red Cross, the mark of one million suspected cases was exceeded, the World Health Organization names just under a million, of which more than 2,200 deaths. It is considered to be the largest known cholera outbreak in human history. As of April 30, 2019, 1,702,246 suspected cholera cases and 3,438 confirmed deaths were recorded.

    literature

    • Axel Stefek (ed.) Among others: Cholera and cloudy water. The consequences of the outdated infrastructure. In: water under the city. Streams, canals, sewage treatment plants. Urban hygiene in Weimar from the Middle Ages to the 20th century. Abwasserbetrieb Weimar, Weimar 2012, pp. 83–91.
    • Myron Echenberg: Africa in the Time of Cholera. A History of Pandemics from 1817 to the Present. Cambridge University Press, New York 2011, ISBN 978-0-521-18820-3 .
    • Charlotte E. Henze: Disease, Health Care and Government in Late Imperial Russia: Life and Death on the Volga, 1823-1914. Routledge, Oxon (UK) 2011, ISBN 978-0-415-54794-9 .
    • Ernst Visser: Urban Developments in the Time of Cholera: Vienna 1830-1850. Dissertation, Central European University - History Department, Budapest 2011.
    • Neil E. Gibson (Commentator): A single dose of azithromycin was more effective than ciprofloxacin for severe cholera in men in Bangladesh. In: Evidence-Based Medicine. No. 11, 2006, p. 181, doi: 10.1136 / ebm.11.6.181 .
    • Steven Johnson : The Ghost Map. The Story of London's Most Terrifying Epidemic - and How It Changed Science, Cities, and the Modern World. Riverhead Books, New York 2006, ISBN 1-59448-925-4 .
    • Harvey F. Lodisch: Molecular Cell Biology. 4th edition. Spectrum Academic Publishing House, Heidelberg / Berlin 2001, ISBN 3-8274-1077-0 .
    • Gerold Schmidt: “Cholera newspapers” from 1831 to 1832 as a biographical-genealogical source. In: Genealogy. German magazine for family studies. No. 46, 1997, pp. 708-736.
    • Barbara Dettke: The Asian Hydra. The cholera of 1830/31 in Berlin and the Prussian provinces of Posen, Prussia and Silesia. De Gruyter, Berlin 1995, ISBN 3-11-014493-X . (GoogleBooks)
    • Richard J. Evans : Death in Hamburg. City, Society and Politics in the Cholera Years 1830–1910. Rowohlt, Reinbek 1990, ISBN 3-498-01648-2 .
    • Emil Schultheiß, Louis Tardy: Short history of epidemics in Hungary until the Great Cholera Epidemic of 1831 (on the basis of historical sources). In: Centaurus 11, 1966, pp. 279-301.

    Web links

    Wiktionary: Cholera  - explanations of meanings, word origins, synonyms, translations
    Commons : Cholera  - album with pictures, videos and audio files
    Wikisource: Cholera  - Sources and Full Texts
     Wikinews: Cholera Epidemic: Zimbabwean Government Accuses the West of Biological Warfare  - Message
     Wikinews: South Africa declares a state of emergency in the border area with Zimbabwe  - news
     Wikinews: Zimbabwe faces a cholera disaster  - news
     Wikinews: Cholera Epidemic in Zimbabwe  - News

    Individual evidence

    1. ↑ Ulrike Roll: Cholera. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , pp. 257 f.
    2. ↑ Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 142-144 ( Cholera ).
    3. ↑ Manfred Vasold: The mortality in Nuremberg in the 19th century. Living conditions, illness and death (around 1800 to 1913). In: Würzburg medical history reports. Volume 25, 2006, pp. 241-338, here: p. 277.
    4. ↑ Ulrike Roll: Cholera. Berlin / New York 2005, p. 258.
    5. ↑ a b Real Academia de la Historia (ed.): Joaquín Balcells y Pasqual , 2018, archive link (Spanish)
    6. ↑ Col·legi Oficial de Metges de Barcelona (ed.): Joaquim Balcells i Pascual , 2015, archive link ( Catalan )
    7. ↑ da Costa Simões, António Augusto / de Macedo Pinto, José Ferreira: Relatório da Direcção do Hospital de Cholericos de NS da Conceição em Coimbra , 1856, Coimbra: Imprensa da Universidade (Portuguese, link to the catalog of the library of the University of Coimbra, which contains the Works in stock )
    8. ↑ Anna Philine Schlagberger: The ideas and knowledge of the mode of action of the cholera pathogen Vibrio cholerae in the course of time. Dissertation . Ludwig Maximilians University of Munich, 2009 ( PDF file )
    9. ↑ DL Swerdlow, ED Mintz, M. Rodriguez et al .: Severe life-threatening cholera associated with blood group O in Peru: implications for the Latin American epidemic . In: J. Infect. Dis. tape 170 , no. 2 , August 1994, p. 468-472 , PMID 8035040 .
    10. ↑ JB Harris, AI Khan, RC LaRocque et al .: Blood group, immunity, and risk of infection with Vibrio cholerae in an area of ​​endemicity . In: Infection and Immunity . tape 73 , no. 11 , November 2005, p. 7422-7427 , doi : 10.1128 / IAI.73.11.7422-7427.2005 , PMID 16239542 , PMC 1273892 (free full text).
    11. ↑ Data sheet TCBS agar for the isolation and selective cultivation of Vibrio cholera (PDF) from Merck , accessed on January 21, 2011.
    12. ↑ TCBS Cholera Agar, modified (Thiosulfate Citrate Bile Sucrose Agar) (Cholera Agar) Item No. CM 333, OXOID manual p. 293 online (PDF file; 42 kB)
    13. ↑ M. Cheesborough: District Laboratory Practice in Tropical Countries. 2nd Volume, Cambridge University Press, Cambridge, New York 2005-2006, ISBN 0-521-67631-2 , pp. 189-194.
    14. ↑ a b WHO : Oral Rehydration salts: Production of the new ORS. ( WHO drinking solution ) ( full text as PDF file; 2.29 MB )
    15. ↑ a b c d e Prevention and control of cholera outbreaks: WHO policy and recommendations. In: origin.who.int. Retrieved November 18, 2019 .
    16. ↑ Mark N. Frühwein: cholera. In: apotheken-umschau.de. April 17, 2018, accessed November 18, 2019 .
    17. ^ Antibiotic Treatment - Treatment - Cholera - CDC. In: cdc.gov. January 20, 2015, accessed November 18, 2019 .
    18. ↑ SODIS: How it works , SODIS
    19. ↑ Simple tool to prevent cholera: a water filter made of folded fabric
    20. ↑ 8th Congress for Infectious Diseases and Tropical Medicine 2005, Prof. Dr. Thomas Weinke: Cholera vaccination: is it useful and for whom? (PDF file; 86 kB)
    21. ↑ Profiles of rare and imported infectious diseases. (PDF) (No longer available online.) In: Website of the Robert Koch Institute (RKI). September 15, 2011, archived from the original on December 30, 2013 ; Retrieved November 6, 2013 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.rki.de
    22. ^ AS Vicari, C. Ruiz-Matus et al. a .: Development of a cholera vaccination policy on the island of hispaniola, 2010-2013. In: The American journal of tropical medicine and hygiene. Volume 89, Number 4, October 2013, pp. 682-687, ISSN  1476-1645 . doi: 10.4269 / ajtmh.13-0200 . PMID 24106195 . PMC 3795098 (free full text).
    23. ↑ KT Hamorsky, JC Kouokam et al. a .: Rapid and scalable plant-based production of a cholera toxin B subunit variant to aid in mass vaccination against cholera outbreaks. In: PLoS neglected tropical diseases. Volume 7, number 3, 2013, p. E2046, ISSN  1935-2735 . doi: 10.1371 / journal.pntd.0002046 . PMID 23505583 . PMC 3591335 (free full text).
    24. ↑ Notifiable communicable diseases and pathogens. (PDF, 114 kB) Overview of mandatory reporting 2020. Federal Office of Public Health FOPH, Communicable Diseases Department, January 23, 2020, accessed on March 8, 2020 (flyer with tabular overview).
    25. ^ Until the 1830s, the autumn fog was held responsible for the transmission. Many households avoided fruit because there was suspicion that it was causing the infection. ( The Times , Aug. 14, 1879, p. 9)
    26. ↑ Joseph Griffiths Swayne , wikisource
    27. ^ Michael Whitfield: The Bristol Microscopists and the Cholera Epidemic of 1849. Avon Local History and Archeology 2011, ALHA Books, Bristol 2011.
    28. ^ Wikisource William Budd
    29. ↑ JG Swayne; W. Budd: An account of certain organic cells in the peculiar evacuations of cholera. In: Lancet. 54, 1849, pp. 398-399.
    30. ^ PE Brown: John Snow - the autumn loiterer. Pp. 519-528, online
    31. ↑ Milton Wainwright: Microbiology before Pasteur. In: Microbiology Today. Volume 28, February 2001, p. 20 ( full text as PDF ).
    32. ^ Stephanie J. Snow: Death by Water. John Snow and the cholera in the 19 th century. Liverpool Medical History Society. 4 March 1999.
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