Indmedica Home | About Indmedica | Medical Jobs | Advertise On Indmedica
Search Indmedica Web
Indmedica - India's premier medical portal

Indian Journal of Community Medicine

An Explosive Outbreak of Multidrug Resistant EL Tor Cholera in a Rural Community of Gujarat State

Author(s): Pradeep Kumar

Vol. 30, No. 4 (2005-10 - 2005-12)


Cholera is a major infectious disease with epidemic potential, especially among communities living in congested urban slums and vast rural areas without proper sanitary facilities. The epidemiology of cholera showed remarkable changes soon after the introduction of EL Tor biotype of V. cholerae in India in 1964. Multidrug resistant EL Tor V. cholera was first reported as early as 1977 from Tanzania, which was followed, by several such reports from all over the world1,2 especially to drugs like Tetracycline and Furazolidone. The present communication deals with the results of investigation of an explosive EL Tor cholera outbreak during 30th September to 15th October in a rural area attached to Community Health Center (C.H.C.) Padra of District Baroda in Gujarat state.


The investigation was carried out on two consecutive days i.e. 2nd and 3rd October 2002 in the village Kanzat under C.H.C. Padra where no major epidemic had occurred since the last 6 years. Pipelines from an overhead tank were supplying drinking water. A house-to-house survey using a standard proforma was carried out to detect all cases and deaths due to diarrhea. General living conditions and specifically storage of drinking water was noted. All detected diarrhoeal cases were clinically assessed using standard WHO guidelines3 and the treatment they received were recorded. During house-to-house survey, the drinking water was tested for chlorination with Orthotoluidene reagent. The test turned out to be negative at one house. The diarrhoeal cases were immediately provided with appropriate management as per WHO guidelines. Health education was imparted to the people regarding the disease, its mode of spread and water sanitation. Tetracycline/ Doxycycline was administered to the contacts as chemoprophylaxis. The health authorities were instructed to arrange for super chlorinated water tankers for supply of drinking and cooking water.

The initial 15 faecal samples collected in Venkataraman Ramakrishnan (VR) media from the patients presenting at PHC Kanzat were sent to Public Health Laboratory, Vaccine Institute Vadodara for bacteriological examination. Subsequently, 33 faecal samples from the patients collected in VR media were sent to the Microbiology Department at Medical College Vadodara. A preliminary hanging drop preparation was carried out on each sample prior to bacteriological processing. Part of the sample was enriched in Alkaline Peptone Water (APW) and then sub cultured on to a non-selective media i.e., Nutrient Agar as well as on a selective media i.e., Thiosulphate Citrate Bilesalt Sucrose Agar (TCBS) for the detection of Vibrio species. Subcultures were simultaneously done on MacConkey's agar and Deoxycholate Citrate Agar (DCA) to rule out other agents like Salmonella, Shigella, E. coli etc. The isolates were identified using standard techniques4. Antimicrobial susceptibility testing was done by using modified Kirby Bauer disc diffusion technique5 to the following antibiotics: Amikacin (10mcg), Carbenicillin (100mcg) Chloramphenicol (30mcg), Cefotaxime (30mcg), Ciprofloxacin (10mcg) Gentamycin (10mcg), Norfloxacin (10mcg), Clindamycin (2mcg), Cloxacillin (1mcg), Cephalexin (10mcg), Tetracycline (30mcg) and Co-trimoxazole (25mcg). Strains of V. cholerae isolated were sent to the Diarrhoeal Disease Research and Training Institute (ICMR) Calcutta for phage typing. Water samples were collected in 500ml sterile bottles from the leaking pipelines and sent to Public Health Laboratory and Vaccine Institute Vadodara for bacteriological examination.

Results and Discussion:

Village Kanzat has a population of around 3900 with 625 households. Most of the people are cultivators while a few are labourers. The living conditions were poor with overcrowding and poor general and personal hygiene. Though most of the houses had piped water supply, drinking water was being stored in earthen and cement vessels. Due to the absence of sanitary latrine facilities most of the families resorted to openair defecation. Indiscriminate disposal of dead animals was also noted. The source of infection was contaminated drinking water due to the leakage of the supplying pipelines. The distribution of cases was as that seen in a common source outbreak. The outbreak started on 30th September 2002 and the maximum numbers of cases were noted on 3rd October, declining slowly thereafter. 300 cases of acute watery diarrhea with vomiting occurred giving an overall attack rate of 8% with almost all age groups being affected (Table I). The 1st case was a 23 yr old female who presented with profuse watery diarrhea and vomiting. She had to be hospitalized but was discharged after responding to treatment. Other cases requiring hospitalization were treated at the respective PHC, CHC, and S.S.G. Hospital Baroda. Few were treated on a domiciliary basis. Only one death was recorded during the entire epidemic.

Table I: Age Distribution in Diarrhoeal Cases

Age (years) Hospitalised Cases Domiciliary Cases Total
< 4 16 (42.10%) 22 (57.90%) 38
4-14 45 (46.40%) 52 (53.60%) 97
> 14 49 (29.70%) 116 (70.30%) 165
Total 110 (36.67%) 190 (63.33%) 300

V. cholerae 01 biotype EI Tor Serotype Ogawa Phage type 4 (Basu and Mukherjee) was isolated as a single pathogen from 24 out of the 48 stool samples screened, giving a positivity rate of 50%. (9 of them were ages 0-14 years and 15 were aged 15 years and above). From the 5 water samples collected from the various leaking water pipelines, 4 (80%) were positive for V. cholerae 01. Antibiotic susceptibility pattern of the isolates revealed that all the strains were uniformly sensitive to Amikacin, Gentamycin, Chloramphenicol, Norfloxacin, Ciprofloxacin and Cefotaxime but were resistant to Tetracycline, Cotrimoxazole, Carbenicillin, Clindamycin, Cloxacillin and Cephalexin. Other workers in India6,7 have also reported multidrug resistance specifically to Tetracycline, Cotrimoxazole and others. The resistance of the isolated V. cholerae strains to the two first line drugs namely Tetracycline and Co-trimoxazole represents a critical public health problem for the developing third world countries. This is because most of the population in such countries cannot afford more effective but expensive antibiotics. The resistance of V. cholerae to anti-microbials has now been established to be plasmid mediated1,2.


Vibrio cholerae 01 was the major cause of the acute diarrhoeal outbreak as is evident from the clinical, epidemiological and microbiological data of this localized and explosive outbreak. The most probable cause was contamination of the drinking water source due to the indiscriminate defaecation and low levels of personal and domestic hygiene. The fast emergence of Multidrug resistant V. cholerae specifically to the drugs recommended by WHO for control of cholera is a cause for major concern. Mass chemophylaxis in the control of cholera should be discouraged unless evidence to the contrary becomes available.


  1. Glass RI, Huq I, Alim A R M A, Yunus M. Emergence of Multiply Antibiotic Resistant Vibrio cholerae Bangladesh. J Infect Diseases 1980; 142: 939-942.
  2. Maimone F, Coppo A, Pazzani C, Ismail SO, Guerra R, Procacci P, Rotigliano G, Omar K H. Clonal Spread of Multiply Resistant Strains of Vibrio cholerae 01 in Somalia J Infect Diseases 1986; 153:802-803.
  3. A Manual for the treatment of acute diarrhea: For use by physicians and other senior Health workers. Programme for control of diarrhoeal diseases. World Health Organization (WHO) Geneva; 1984.
  4. Porter IA, Duguid J P. Vibrio. Aeromonas: Pleisomonas: Spirillum: Campylobacter, In Mackie and McCartney, Practical Medical Microbiology 13th ed. Collee JG, Duguid JP, Fraser. AG, Marmion. BP, Editors (Churchill Livingstone; Edinburgh) 1990:505-524.
  5. Bauer A W, Kirby W M, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol 1966; 45:493.
  6. Anand VK, Arora, Patwari A K., Agarwal G D, Dewan N. Multidrug Resistance in Vibrio cholerae. Indian Paediatrics 1996; 33(9): 774-777.
  7. Fule R P, Powar R M, Menon S, Basutkur SH, Saoji A.M. Cholera Epidemic in Solapur during July-August, 1998. Indian J Med Res 1990; 91:24-26.

Deptt. of PSM, Govt. Medical College, Surat.

Access free medical resources from Wiley-Blackwell now!

About Indmedica - Conditions of Usage - Advertise On Indmedica - Contact Us

Copyright © 2005 Indmedica