Global warming, rising sea level, and growing risk of cholera incidence: A review of the literature and evidence

The survival of Vibrio cholerae -the pathogen agent of cholera- in aquatic environments is linked to both abiotic and biotic ecological factors, which are likely to be influenced by global climate changes and the resulting rise in sea level. Yet little attention has been paid to the possible impacts of these predicted global environmental changes on water-borne diseases such as cholera. The probable ecological mechanisms to explain why cholera may increase if predicted global warming and sea level rise do occur have, as yet, not been addressed. The objective of this paper is to argue the hypothesis that the survival of Vibrio cholerae in aquatic environments may be favoured by global warming and flooding of low-lying coastal areas due to rising sea level. Those changes may enhance primary and secondary transmission of cholera in developing nations, particularly among populations settled in low-lying coastal areas of tropical regions. Primary transmission is also likely to increase in developed nations, mainly among populations living in low-lying coastal areas of subtropical and temperate regions, where new loci of hypoendemic cholera may appear. Nevertheless, if current high levels of hygienic standards in developed nations are relaxed, secondary transmission of cholera may also increase. The prediction and assessment of the potential impact of global climate change on cholera epidemic and endemic potential and its geographical distribution should consider the role of the aquatic reservoirs of Vibrio cholerae in the transmission and endemicity of cholera. The geographical distribution of cholera depends not only on social and cultural factors, but also on ecological variables. On the other hand, global climate changes may cause different impacts in different ecosystems and geographical landscapes. Hence it would be useful to calculate and map future cholera incidence rates for areas defined by natural boundaries, such as ecosystems and geographical landscapes, in search of space-time associations between cholera incidence rates and environmental changes.