Original Article

An epidemic outbreak of Vibrio Cholerae El Tor

01 serotype ogawa biotype in a Lalpur town,
Jamnagar, India
Shah HD, Shah VP1, Desai AN2

Departments of
Community Medicine,
1
Microbiology, and
2
Medicine, MP Shah
Medical College,
Jamnagar, Gujarat, India
Address for correspondence:
Dr. Harsh Shah,
E‑mail: harsh.423@gmail.
com
Received : 27‑08‑11
Review completed : 26‑09‑11
Accepted : 04‑10‑11
Abstract
Background: On December 19, 2010, 57 cases of gastroenteritis were reported in the community health center
of Lalpur town. A rapid response team was sent to investigate the outbreak on December 21, 2010. Aim: To
identify the source, to institute control and prevention measures. Materials and Methods: The outbreak was
confirmed using the previous Integrated Integrated Disease Surveillance Project (IDSP) data. Detailed history
was taken, line listing of patients and house‑to‑house investigations were done. Environmental investigation
and laboratory investigation of stool samples were also done. As the study was conducted during emergency
response to the outbreak and was designed to provide information to orient the public health response, ethical
approval was not required. Remedial measures were implemented. Results: Three hundred and thirty cases
were reported during December 19, 2010 to January 2, 2011 in Lalpur town of Jamnagar district. Nineteen
patients were found to be positive for Vibrio Cholerae 01 serotype ogawa biotype out of 117 stool samples.
The mean age of patients was 24.23±19.01 years. The outbreak had 1.88% attack rate with no mortality and
59.1% cases had to be admitted. Investigations revealed that the epidemic was waterborne. Ten leakages
were found in the pipelines of the affected areas of Lalpur town near two riverbanks. Conclusion: Among
identified gaps, delays in the initiation of the investigation of the epidemic and repairing of leakages were most
important. In India, waterborne epidemics are usual occurrences during the year. In this scenario, the village
health and sanitation committee and water board should follow guidelines, and monitoring of water sources,
proper sewage disposal and sanitation measures should be undertaken.
KEY WORDS: Cholera, Lalpur town, Jamnagar, outbreak investigation, waterborne outbreak

Introduction the family enterobacteriaceae. The species V. Cholerae includes

both pathogenic and nonpathogenic strains, differing in their

C holera is an infection that leads to an acute diarrheal

disease with a large cluster of cases.[1] Cholera remains
a major public health problem since decades in developing
virulence gene contents and polysaccharide surface antigens.
Only V. Cholerae O1 and O139 are responsible for the disease
defined clinically and epidemiologically as cholera.[1] V. Cholerae
countries like India, where six of the seven pandemics began.[1‑3] O1 is divided into classical and El Tor biotypes, and into three
Every year about 3‑5 millions cases occur, from which about sero‑subtypes, Ogawa, Inaba and Hikojima. V. Cholerae O139
120,000 to 100,000 patients die.[4] has characteristics in common with the El Tor biotype in India,
but differs from O1 in its polysaccharide surface antigens.[5‑7]
V. Cholerae is a curved Gram‑negative bacillus that belongs to
the family vibrionaceae and shares common characteristics with Previous studies have shown that up to 80% cases of acute
diarrhea can be treated successfully with timely intervention
Access this article online like oral rehydration salts.[4,8] As cholera can spread both through
Quick Response Code: Website: fecal contamination of food and water by humans and through
www.jpgmonline.com independent propagation of the pathogen in the environment,
DOI: the environment plays a crucial role.[9‑11] Cholera mostly happens
10.4103/0022-3859.93247 with an outbreak, i.e. a large number of cases within a short
time so there is need of timely identification, preparedness and
PubMed ID:
response to outbreak control.[4] Widespread availability of Oral
***
Rehydration Solution proper sanitation measures and adequate

 14 Journal of Postgraduate Medicine January 2012 Vol 58 Issue 1

 Shah, et al.: An investigation of outbreak of vibrio cholera in Lalpur town, Jamnagar, India
personal hygiene help the community to prevent cholera from
becoming an epidemic outbreak.[8,9] It is important to obtain
epidemiological data on diarrheal outbreaks to formulate control
and preparedness plans which suit a particular affected area with
population‑specific needs.
This study aimed to find the reasons for the epidemic and
focused on identification of gaps in the management of the
epidemic with application of remedial measures in the V.
Cholerae outbreak caused by V. Cholerae El Tor 01 biotype,
Ogawa serotype in Lalpur block, Jamnagar.
Materials and Methods
Descriptive epidemiology
After receipt of information about an outbreak of gastroenteritis
by the surveillance team, a rapid response team from a tertiary
teaching hospital, Jamnagar in Lalpur town having population
of 17550, undertook the investigation and management of
the epidemic on December 21, 2010. A case of diarrhea was
defined as the occurrence of more than three watery stools
a day among residents of the town.[12,13] From the detailed
history of indoor and outdoor patients at the community
health center of Lalpur town and the tertiary hospital, which
is a tertiary teaching hospital of Jamnagar district, the affected
localities were identified [Figure 1]. All the diarrhea cases had
high frequency of loose stools more than three times with or
without rice water appearance. We reviewed the Integrated
Disease Surveillance Project (IDSP) annual report to confirm
the outbreak of diarrheal disease.[12] The case definition was
consistent with cholera disease outbreak. The house‑to‑house
survey was done with 12 teams of 24 health workers and line
listing of all suspected cases of cholera was done. The cases
that were admitted in Community health center and referred
cases of the tertiary hospital were also included in the study.
Information regarding age, sex, place of residence, date of
onset and days of hospital admission, treatment and laboratory
finding was collected. The hypotheses were generated based
on the characteristics of the person, time and place of the
Figure 1: Geographical map and affected areas during cholera
outbreak, December 2010, Lalpur town
Journal of Postgraduate Medicine January 2012 Vol 58 Issue 1 15 
outbreak. The epidemic curve was constructed to describe the
development of the outbreak over time and cases were plotted
on the geographical map of the town to plan action for control
of the outbreak.
Environmental investigation
After reviewing the descriptive epidemiology and hypotheses‑
generating interviews, epidemic occurrence pointed to a
contaminated water supply, and the investigation teams
visited house to house and collected information regarding
water quality, sources of water supply and drainage system.
The information of mass gathering, exposure to mass food
consumption was also included in the questionnaire. We
also interviewed the water supply department and the local
community members to enquire about the general water supply
and sanitation situation. About 10 random water samples were
taken from affected areas.
Laboratory investigation
Most of the patients had loose rice watery diarrhea. Stool
samples were collected randomly and inoculated in alkaline
peptone water from patients who had complains of diarrhea,
admitted to two hospitals–community health center, Lalpur
and tertiary hospital, Jamnagar. A total 117 stool samples
during December 19, 2010 to January 2, 2011 were tested by
standard bacteriological techniques.[14] Anti‑microbiological
susceptibility of isolated pathological organisms was done by
disc diffusion technique.
Ethical consideration
This study was conducted during the emergency response to
the cholera outbreak and was designed to provide information
to orient the public health response, ethical approval was not
sought prior to the survey. It was undertaken as a public health
practice rather than a research.[15,16] Privacy, confidentiality and
rights of patients were ensured during and after the conduct of
the study. Oral informed consent was obtained in each visited
household after detailed explanation of the existence of an
outbreak, the objective of the study and the planed use of the
information. Moreover, health education was carried out in
each household regarding cholera transmission and prevention.
The information was entered and analyzed anonymously. The
study was implemented in collaboration with the district health
officials after obtaining authorization to carry out the survey.
Results
Descriptive epidemiology
The surveillance data of the past three months of the Jamnagar
district and Lalpur town from the IDSP was analyzed which
showed that on December 19, 2010, there was an unusual
abrupt increase in case incidence of acute diarrheal diseases
in the Community Health Center, Lalpur town which has a
population of 17,550 and with 2700 households. The town is
located between two rivers named Dhandhar and Roopavati.
Most of the patients came with the complaints of increased
frequency of loose watery diarrhea and a few had vomiting for
the past two days. Further investigation ruled out population
influx or any change in reporting system. This episode was
 Shah, et al.: An investigation of outbreak of vibrio cholera in Lalpur town, Jamnagar, India

declared as a cholera outbreak on December 24, 2010 after 70

confirmation of the presence of Vibrio Cholerae in laboratory 62

60 57
reports. It lasted up to January 2, 2011.
50 48
46
42
The flow of indoor as well as outpatient department (OPD)
40

Frequency
cases was identified. A total of 330 patients reported with an
attack rate of 1.88% in the outbreak, during the time period 30

from 19 December 2010 to 2 January 2011. Out of 330 patients, 19

20
195 (59.1%) cases were kept on indoor treatment basis and out 16
11
of them, 58 (29.74%) patients were referred to a tertiary care 10
9
5
teaching hospital of Jamnagar district. No mortality occurred 3 2
0 0 1
0
during the epidemic. Almost an equal number of males and

18 10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

11

11
2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

2-

1-

1-
females were affected during the outbreak. There was an initial

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-1

-0

-0
17

19

20

21

22

23

24

25

26

27

28

29

30

31

01

02
Dates
increase in cases on December 19, followed by progressive
decrease in cases. The second part of the epidemic curve Figure 2: Epidemiological curve of cholera outbreak, December 2010,
[Figure 2] was stretched due to secondary person‑to‑person Lalpur town
transmission, which is consistent with outbreaks of cholera.
Table 1: Age distribution of patients during cholera
The geographical map of the affected area was structured with outbreak, December 2010, Lalpur town (N=330)
the help of information gained from interviews of indoor and Age distribution (Years) Frequency Percentage
OPD patients [Figure 1]. The same has been plotted on the 0‑10 99 30
map to see the place distribution of the outbreak.
11‑20 78 24
21‑30 53 16.3
Table 1 shows the age distribution of the affected persons. Mean
age of patients was 24.23±19.01 years. The majority of the 31‑40 37 11.2
patients had loose watery diarrhea more than three times, and 41‑50 25 7.5
vomiting on and off. The clinical features and stool macroscopy 51‑60 25 7.8
were also consistent with cholera findings. >60 13 4
Total (N) 330 100
Environmental investigation
For house‑to‑house survey, a total of 12 teams of health workers
were made and given the interview questionnaire. They Table 2: Sex pattern of total patients and positivity rate
collected information regarding age, sex, clinical features, water among them during cholera outbreak, December 2010,
storage container, water supply of households and drinking water Lalpur town
sources. They found ten leakages in the water pipelines from the Frequency Percentage
affected areas. But super chlorination of water sources was done Case patients (n=330)
by local water board authorities before acquiring the samples, Males 168/330 51
to prevent further transmission among the population. So the Females 162/330 49
test result of water samples came negative and fit for drinking. Positive samples (n=117)
Males 7/69 10.1
Laboratory investigation
Females 12/48 25
Out of 330 cases, 117 stool samples were collected in alkaline
peptone water, from which 19 samples were found positive for
Vibrio Cholera El Tor Serotype, Ogawa [Table 2]. In addition, the rivers Dhandhar and Roopavati. These rivers are the prime
antibiotic susceptibility of isolated pathological organism was drinking water sources of Lalpur town. The majority of the patients
done by disc diffusion technique. For further investigation of came from the areas near the riverbanks; Dhararnagar, Mazjid
phage typing, samples were sent to NICED, Kolkata. street, Husaini chowk, Madresa chowk, vagharivas [Figure 1].
Almost 90% of patients had complaints of diarrhea, vomiting and
Thus, a hypothesis was generated that contaminated drinking other signs of dehydration within hours on December 19, 2010.
water could have been the reason of the cholera epidemic For the remaining cases, there was no specific explanation. A
outbreak from leakages found in water supply pipelines and rapid response team was called on December 21, 2010 from local
bore wells. health authorities so there was two days of delay for initiation of
epidemic investigation and management. During investigation,
Discussion we found 10 leakages in water pipes and bore‑wells of affected
areas that contaminated the drinking water. The leakages were
An outbreak of cholera occurred in the Lalpur, Jamnagar district not repaired until five days of the outbreak because of technical
in December 2010. After investigation, it was revealed that the difficulties. The second part of the peak of the epidemic curve had
outbreak occurred because of contaminated drinking water due to 22.47% patients who had contracted the disease due to secondary
leakages found in the water pipes and bore‑wells of localities near person‑to‑person transmission [Figure 2].

 16 Journal of Postgraduate Medicine January 2012 Vol 58 Issue 1

 Shah, et al.: An investigation of outbreak of vibrio cholera in Lalpur town, Jamnagar, India
Contaminated water remains the prime vehicle for outbreaks
of cholera in developing countries like India. Here at Lalpur,
the affected areas near riverbanks are mostly slums. They have
poor sanitation practices, lack sewerage and toilets at residence.
So fecal contamination through leakages of water sources of
households could be one of the possibilities.[9] The third target
of the Seventh Millennium Development Goal of the United
Nations proposes to halve the proportion of people who are
unable to reach or afford safe drinking water between 1990 to
2015.[15] As per the United Nations’ criteria, improved drinking
water sources include household water connections, public
water pipelines, bore‑wells, and protected dug wells, springs
and rainwater collection. In spite of political commitment and
well‑directed efforts, still in some parts of India, people do not
have access to safe drinking water.[17]
National surveys have shown that only 28% families in rural areas
have access to pipe water. The majority of the households use
water from bore‑wells (53%). Still about one in eight families
uses unsafe sources of drinking water like unprotected wells.
Sixty‑six percent households do not boil or treat their drinking
water at home.[18]
Indicator 7.8 of Goal seven is the proportion of population
using an improved drinking water source.[19] It has increased
from 66% in 1990 to 84% in 2008 in India. With this rate, it
might be possible to reach this target by 2015 but occurrences
of waterborne epidemics are also common in towns and cities.[20]
The proportion of people using an improved sanitation facility
though, remains a great challenge. Improper sanitary conditions
lead to outbreaks of waterborne diseases.[9] From a dismal 7%
in 1990 this figure has only improved up to 31% in 2008.[19]
India should strengthen the implementation to obtain
the targets with strong commitment and with dedicated
efforts, because it is challenging task to achieve the seventh
Millennium Development Goal that is “Ensure environmental
sustainability” and its indicators 7.8 and 7.9 in this scenario.
Our investigation revealed that the leakages in water pipes and
bore‑wells were the cause of this outbreak, which do not fall
under improved water sources as per Millennium Development
Goals criteria. This outbreak is a classical example of waterborne
disease outbreak. There had been other reasons also, which
could be the sources or agents during the outbreak. The second
part of epidemic curve started on December 24, having a
frequency of 22.72% of the total patients. During this period,
transmission might have been person‑to‑person transmission.
During outbreaks of cholera, it is commonly seen that more
than one source are the cause.[21]
Similar to past studies of diarrheal diseases outbreaks, there
were certain limitations in the investigation: First, the initial
cases of dehydration were not following the established
hypothesis with a wide variation in the history of suspected
diseases. [21] Subsequent house‑to‑house visits revealed
contaminated drinking water as the main reason of the
epidemic. Second, we could only obtain laboratory confirmation
from the limited numbers of indoor patients. Thus, we could
Journal of Postgraduate Medicine January 2012 Vol 58 Issue 1 17 
not exclude other causes, which may be acting together or on
their own to cause this outbreak. However, 19 positive patients
out of 117 tested patients confirmed the outbreak of V. Cholerae
[Table 2]. So our suspicion of V. Cholerae was based on case
definition compatible with V. Cholerae definition of IDSP and
diagnosis of V. Cholerae.[12] Patients with complaints of diarrhea,
vomiting and dehydration, irrespective of lab confirmation
were also treated. Fourth, asymptomatic persons were not
asked about history of similar episodes and not tested for stool
examination. The above limitations could have had an impact
on the association of the outbreak and Vibrio Cholerae, but
either way our recommendation would be the same.
Hence, it is proved that contamination of drinking water by
sewage leads to possibilities of an epidemic outbreak. In Lalpur
town, use of contaminated drinking water from the leaking
water pipes and bore‑wells near the riverbank areas lead to a
cluster, and then possibly was followed by person‑to‑person
transmission. With the confirmation of hypothesis and thorough
investigation, we formulated a number of recommendations and
advised certain interventions for both immediate action and
prevention of future events. For immediate remedial action,
the community was informed without making them panic,
with proper education regarding safe drinking water, use of
chlorine tablets and proper sanitation measures. Second, super
chlorination of water sources was done during the outbreak and
chlorine tablets were distributed by making house‑to‑house
visits in the affected areas with Information Education and
Communication materials. Third, on future preventive
measures, the Village Health and Sanitation Committee and
Taluka Panchayat authorities were advised to check the water
sources for contamination on a monthly basis. Additionally,
it is important that proper sewage treatment should be done
before draining it into the river. The village health and sanitation
committee can help in this regard for guidance and resources.
Fourth, the district authorities should make sure that this type
of leakages and contamination would not occur again and
continuous monitoring should be done. Fifth, all residents of
the town should be educated regarding proper household water
storage, water disinfection by boiling and chlorination, healthy
sanitation measures like clean sewage treatments, proper hand
washing and oral rehydration therapy in case of dehydration.
To summarize, not only drinking water but safe drinking water
should be made available to succeed in achieving the seventh
Millennium Development Goal. In addition, it will control the
waterborne epidemics which are usual occurrences in India.
Standardized indicators of the Millennium Development Goals
will help to monitor the progress of the objectives in the long
run.
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How to cite this article: Shah HD, Shah VP, Desai AN. An epidemic outbreak
of Vibrio Cholerae El Tor 01 serotype ogawa biotype in a Lalpur town,
Jamnagar, India. J Postgrad Med 2012;58:14-8.
Source of Support: Nil, Conflict of Interest: None declared.

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