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 vibrio cholerae are commonly found in seas , estuaries , brackish water , rivers , and pond water of coastal areas .
cholera is characterized by profuse watery diarrhea , vomiting , abdominal cramps , circulatory collapse , and shock .
morbidity of cholera provides acute suffering , monitory loss , and probability of impending epidemic . as a consequence mortality due to cholera
surface water is frequently contaminated with v. cholerae and rural people often remain in close contact with surface water .
rural people usually used these water for washing utensil and garments , bathing , and preparation of foods .
it was estimated in 2010 that 35 million people suffered from cholera and more than 100,000 people died due to cholera worldwide .
a total of 13,819 cholera cases were reported from 14 countries of asia in 2010 with a 50% increase in the number of cases than 2009 . in 2010 ,
sixty - eight outbreaks of cholera which were reported in india during 1997 to 2006 affected more than 200,000 cases and 823 deaths . in 2010 , 192 cholera cases were reported in west bengal .
eleven diarrhea outbreaks were reported in the district of purba medinipur in 2011 , of which none were confirmed using laboratory facilities .
health workers informed the block medical officer of health ( bmoh ) of kharipukuria block that there were increased numbers of diarrhea cases in haibatpur village .
the outbreak was investigated with the following objectives : to confirm the existence of the diarrhea outbreak , find out the risk factors , and propose control measures .
the subcenter and the diarrhea affected village were visited and reviewed for diarrhea case records of last three years .
we looked for any population influx in the village and also checked for any change of case definition and surveillance system .
a diarrhea case was defined as passing of three or more loose stools in a day among any resident of haibatpur village between june 12 , 2012 , and june 30 , 2012 .
a confirmed cholera case was defined as isolation of v. cholerae 01 or 0139 among diarrhea cases of any resident of haibatpur village between june 12 , 2012 , and june 30 , 2012 . during the investigation ,
three types of dehydration were observed among the cases such as ( i ) no dehydration which includes not enough signs to classify some dehydration and severe dehydration and only  three loose stools within the 24-hour period , ( ii ) some dehydration ( any two of the followings ) such as restlessness and irritability , sunken eyes , drinking eagerly and thirsty , and skin pinch which goes back slowly by less than two seconds , and ( iii ) severe dehydration ( any two of the followings ) such as lethargy and unconscious , sunken eyes , inability to drink , and skin pinch which goes back very slowly ( taking more than 2 seconds ) .
cases were searched for by house - to - house survey of the affected village .
line - listing of cases was done noting name , age , sex , date of onset , signs and symptoms of diarrhea , and outcome of disease .
the attack rate was calculated by age and sex using the population denominator of the village .
the epidemic curve was drawn to show the magnitude of outbreak . to generate hypothesis trawling questionnaires
four rectal swabs were collected from the cases that did not take any antibiotics and sent to the laboratory of school of tropical medicine , kolkata , west bengal , for physical , chemical , and cultural sensitivity test .
five water samples were also collected from different drinking water sources and ponds of the village and sent for examination to the public health laboratory , purba medinipur , for physical , chemical , and bacteriological examination .
the affected areas were inspected and observed for water supply system , drainage system , water storage conditions , kitchen articles , food preparation practices , and sanitary condition of the village cultural beliefs .
cases of patients and villagers were interviewed about source of drinking water , sanitation , and personal hygienic practices .
a case - control study was conducted to test the hypothesis that pond water was associated with the cholera outbreak .
a control was defined as any resident of haibatpur village who did not have  three loose stools a day between june , 12 , 2012 , and june 30 , 2012 , above the age of five years .
panta bhat is a lightly fermented rice - based dish consumed in bangladesh and the eastern indian states of west bengal and assam .
this dish of leftover rice , soaked in water to prevent spoiling , is generally served with salt , onion , and chili .
the population of the village was 780 , of which 703 were above the age of five years .
the total diarrhea cases of same month of last three years were assessed through record review and a total 11 ( 3 + 4 + 4 ) cases were recorded .
this year a total 41 cases were identified at the same month and this was clearly in excess of the expected number of diarrhea cases .
the cases were reported between june 15 , 2012 , and june 28 , 2012 , a total of 14-day period with a peak on june 18 ( figure 1 ) .
total forty - one cases were identified with no death ( case fatality ratio = 0 ) . overall attack rate ( ar ) was 5% ( 41/780 ) .
ar was highest among the age group of > 60 years , 9% ( 5/54 ) , followed by 6% ( 26/264 ) among the age group of 1559 years .
more than 80% ( 33/41 ) of cases developed no dehydration to some dehydration but 20% ( 8/41 ) of cases required intravenous infusion due to severe dehydration .
v. cholerae 01 eltor ogawa was isolated from one stool specimen ( out of four ) .
five water samples were tested ( two pond water samples of the affected village and three tube well water samples from the adjacent villages ) from where the local people collected water for drinking , of which two pond water samples were found contaminated with coliform organism above the maximum permissible number ( mpn ) , indicating fecal contamination .
all the three tube well water samples had no growth and physical quality was good .
all forty - one cases and same number of controls were recruited for the case - control study .
median age for case was 33 ( range 580 ) years compared with the median age of controls which was 34 ( range 675 ) years .
females were 31% and 53% among the cases and controls , respectively . compared to control , cases more likely had used pond water samples for preparation of fermented rice ( or 4.73 , 95% ci : 1.6913.51 ) , had used pond water for washing utensils ( or 7.31 , 95% ci : 1.7742.29 ) , or had history of diarrhea case contact ( or 3.41 , 95% ci : 1.259.47 ) .
cases were less likely those who washed hands after defecation ( or 0.08 , 95% ci : 0.020.31 ) ( table 2 ) .
there was scarcity of safe drinking water in this gram panchayat area due to defective deep tube well .
the villagers were compelled to consume pond water during preparing food , washing utensil , and other day - to - day activities .
they collected drinking water from the nearby villages with the minimum distance of one to three kilometers .
the cases were clustered around the pond and the hypothesis was generated that pond water was associated with the cholera outbreak .
the villagers said that the fermented rice would be tasty when it was prepared with pond water .
three days before the start of outbreak , the index case consumed fast food from the street vendor followed by diarrhea .
the villagers used this pond water for preparation of the fermented rice and washed their utensils and vegetables .
the villagers used contaminated pond water for preparation of fermented rice ( panta bhat ) .
study in dhaka , bangladesh , showed that cholera was transmitted through contaminated food served by street vendor and restaurant caterer .
physical and chemical characteristics of food that supported the survival of v. cholerae o1 and o139 , such as low temperature , high organic contents , increased moisture contents , neutral or alkaline ph hydrogen ion concentration , ph 7 is neutral , < 7 is acidic and > 7 is alkaline . fermented rice had the favorable conditions for survival and transmission of v. cholera .
v. cholerae also can survive in cooked rice , potatoes , eggs , and pasta for more than five days and also in spices including pepper and cinnamon for several days [ 12 , 13 ] .
several foods , fruits , vegetables , sea foods , diary product , poultry , and meat products act as a medium for transmission of v. cholera [ 14 , 15 ] . the contaminated surface water was associated with cholera outbreak studied in kenya .
the villagers also used this pond water for cooking and washing of the cooking utensils and vegetables .
they used to take bath in these two ponds and had a habit of gurgling with this water during bath .
a study in the state of orissa revealed that well ( shallow underground water source ) became contaminated with v. cholerae and people close to the well were affected more than the distant area .
warm weather is suitable for their spread and it is commonly transmitted through fecal - oral route . in this summer season , there was shortage of water ; a small amount of water was retained at the bottom of the ponds . only four stool specimens were collected .
we could not collect more than four stool specimens as cases had consumed antibiotics earlier .
contaminated pond water used for preparing fermented rice and other domestic uses facilitated cholera outbreak .
first , we educated the villagers not to use pond water till diarrheal outbreak was over .
third , we educated the villagers regarding the danger of use of pond water for preparing fermented rice , and benefit regarding washing hands before taking food and after defecation with soap with soap after defecation .
fourth , we recommended repairing the defective deep tube well and arrangement of piped water supply to the villagers .
fifth , we recommended oral cholera vaccine use in cholera endemic areas and research on cultural behaviors during cholera outbreak .
health workers reported an increased number of diarrhea cases at haibatpur village on june 17 , 2012 . 
 this outbreak was investigated with the following objectives : to confirm the existence of diarrhea outbreak , to find out the risk factors , and propose control measures . 
 cases were listed ; spot map and epidemic curve were drawn . 
 attack rate was calculated by age and sex and risk factors were found out by calculating odds ratio ( or ) with 95% confidence interval ( ci ) . 
 rectal swabs were taken and water specimens were collected for laboratory test . 
 forty - one cases of patients were identified with overall attack rate ( ar ) was 5% ( 41/780 ) . 
 ar among men was higher 6% ( 25/404 ) than women . 
 there was no death . 
 v. cholerae 01 eltor ogawa was isolated from one ( 1/4 ) stool specimen . 
 spot map showed cases clustered around two ponds which were contaminated with coliform organisms . 
 the underground water was a bit saline in nature . using pond water for preparation of fermented rice ( panta bhat ) ( or 4.73 , 95% ci 1.6913.51 ) , washing utensil in pond water ( or 7.31 , 95% ci 1.7742.29 ) 
 were associated with cholera outbreak . 
 health education was done to villagers . 
 disinfection of two ponds with bleaching powder was done . 
 we proposed supplying of safe drinking water and repairing defective deep tube well to village .