Potential re-emergence of cholera in Brazil

The recent identification of an autochthone cholera case —the first in 18 years—brings attention to the potential re-emergence of the disease in Brazil. This marks a significant public health concern that underscores the need of interventions to improve access to clean water, sanitation facilities and hygiene behaviours, especially in vulnerable areas. This new case signals possible lapses in preventive measures and the urgent necessity to reinforce health infrastructure and surveillance systems. Cholera, a highly contagious bacterial infection caused by Vibrio cholerae, poses a severe threat in regions lacking essential sanitation services. The disease primarily spreads through contaminated water, leading to severe watery diarrhoea, dehydration, and potentially fatal outcomes if not promptly treated. Despite its high fatality potential, timely and effective rehydration can significantly mitigate mortality risks.1Kanungo S. Azman A.S. Ramamurthy T. Deen J. Dutta S. Cholera.Lancet. 2022; 399: 1429-1440Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar Cholera has consistently been a major public health challenge, especially in developing nations with inadequate water and sanitation infrastructure. While Africa reports the majority of cholera cases,2Weill F.-X. Domman D. Njamkepo E. et al.Genomic history of the seventh pandemic of cholera in Africa.Science. 2017; 358: 785-789Crossref PubMed Scopus (186) Google Scholar recurrent outbreaks also affect the Americas, notably in Haiti and the Dominican Republic.3Veras-Estévez B.A. Chapman H.J. Cholera in Haiti: a public health challenge in the dominican republic and Americas region.Rev Panam Salud Pública. 2023; 47: 1Crossref Scopus (0) Google Scholar The disease first appeared in Brazil in 1991, introduced through Peru, and affected primarily the Amazon region. From 1991 to 2001, Brazil recorded over 168,000 cases and 2000 deaths, predominantly in the Northeast.4Vicente A.C.P. Coelho A.M. 1990s Vibrio cholerae epidemic, Brazil.Emerg Infect Dis. 2005; 11: 171-172PubMed Google Scholar Following a period from 2006 during which only imported cases were reported, the recent case documented by the Brazilian Ministry of Health on 19 April 2024 represents a significant epidemiological event.5Brazil Ministério da Saúde, Secretaria de Vigilância em Saúde e Ambiente, Departamento de Doenças Transmissíveis, Coordenação-Geral de Vigilância de Zoonoses e Doenças de Transmissão Vetorial. NOTA TÉCNICA No 23/2024-CGZV/DEDT/SVSA/MS.https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/notas-tecnicas/2024/nota-tecnica-no-23-2024-svsa-msDate: 2024Google Scholar The incident involving a 60-year-old man from Salvador, the capital of Bahia in Brazil's Northeast, highlights the potential resurgence of cholera in the country. The patient sought medical attention for abdominal discomfort and diarrhoea, with no history of recent travel or known contact with any cholera cases. Diagnostic tests, including stool culture and PCR, were conducted. The stool culture results were positive for Vibrio cholerae. Further, the PCR analysis confirmed the presence of toxigenic Vibrio cholerae O1, serotype Ogawa. This case is particularly concerning given the social and economic context of Salvador, a region characterized by high rates of poverty, violence, and unemployment. These factors can exacerbate the transmission of the disease and complicate control efforts. Consequently, there is a pressing need for an immediate coordinated public health response, which should include enhanced surveillance, public education, and the strengthening of water, sanitation, and hygiene infrastructures. According to a report by the World Health Organization, there has been a multi-country outbreak of cholera since January 2023, leading to its classification as a grade 3 emergency due to geographic expansion and resource shortages. This surge in cholera cases has been particularly pronounced in regions such as Africa, the Eastern Mediterranean, Central America and the Caribbean, Southeast Asia, and the Western Pacific, where factors such as poverty, ongoing conflicts, and climatic events predominantly contribute to exacerbating the spread of the disease.6World Health OrganizationMulti-country outbreak of cholera. External situation report n. 13.2024https://reliefweb.int/report/malawi/multi-country-outbreak-cholera-external-situation-report-13-published-17-april-2024Google Scholar In response to these challenges, and to prevent a potential outbreak, Brazil must swiftly implement comprehensive public health strategies. These should include rigorous contact tracing, public awareness campaigns about hygiene practices, and rapid access to medical treatment for suspected cases. Long-term investments to improve water and sanitation systems are also critical to prevent the spread of cholera.7Wolfe M. Kaur M. Yates T. Woodin M. Lantagne D. A systematic review and meta-analysis of the association between water, sanitation, and hygiene exposures and cholera in case–control studies.Am J Trop Med Hyg. 2018; 99: 534-545Crossref PubMed Scopus (0) Google Scholar,8D'Mello-Guyett L. Gallandat K. Van den Bergh R. et al.Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: a scoping review of current international guidelines.PLoS One. 2020; 15e0226549PubMed Google Scholar The recent case of cholera in Brazil is a stark reminder of the persistent threat posed by infectious diseases and the continuous need for vigilance and preparedness in public health strategies. As we face the possibility of cholera's re-emergence, it is imperative that public health authorities, in collaboration with global partners, reinforce efforts to protect public health and prevent future outbreaks. The authors contributed equally to this manuscript. We declare no competing interests. P.R.M.F. is a research productivity fellow at the National Council for Scientific and Technological Development (CNPq), Brazil. There is no funding source for this study.