Based on results of ecological studies demonstrating that Vibrio cholerae, the etiological agent of epidemic cholera, is commensal to zooplankton, notably copepods, a simple filtration procedure was developed whereby zooplankton, most phytoplankton, and particulates >20 m were removed from water before use. Effective deployment of this filtration procedure, from September 1999 through July 2002 in 65 villages of rural Bangladesh, of which the total population for the entire study comprised Ϸ133,000 individuals, yielded a 48% reduction in cholera (P < 0.005) compared with the control. C holera is a disease that continues to ravage developing countries and reemerges sporadically elsewhere throughout the world. According to the World Health Organization (WHO), 58 countries have officially reported cholera in 2001, with a total of 184,311 cases and 2,728 deaths (1). However, there were 293,113 cases of cholera worldwide in 1998, with 10,586 deaths. These annual figures of WHO actually represent the tip of the iceberg, because the morbidity and mortality caused by Vibrio cholerae is grossly underreported owing to surveillance difficulties and also for fear of economic and social consequences (2). In fact, several cholera endemic countries, e.g., Bangladesh, are not included in the WHO report. In 1991, after almost 100 years without cholera, outbreaks in 16 Latin American countries resulted in Ϸ400,000 reported cases of cholera and Ͼ4,000 reported deaths (3).That cholera is a waterborne disease has long been known (4-6). Furthermore, surface water has been linked with transmission of cholera since the pioneering work of Snow in 1854 (7). Demonstration of the potential for water to transmit cholera was provided by Koch, who, after Pacini first described the Vibrio (8), isolated and characterized the bacterium, which he named Vibrio comma, and was able to find it in pond water used by an Indian community suffering a cholera epidemic (9).The association of pathogenic vibrios with zooplankton was reported in 1973 by Kaneko and Colwell (10) and of V. cholerae with copepods by Huq et al. in 1983 (11). Commensal occurrence of Vibrio spp. in the copepod gut was demonstrated by Sochard et al. in 1979 (12). A few years later, preferential attachment of V. cholerae to copepod surfaces, egg cases, and the copepod oral region was reported by Huq et al. (11). Extensive data have since been accumulated showing that planktonic copepods play a major role in the multiplication, survival, and transmission of cholera (13-17). That environmental V. cholerae O1 can cause cholera has been established by molecular genetic evidence (18).During spring and late summer in Bangladesh, phytoplankton blooms occur, followed by zooplankton, with heaviest blooms occurring in September and October (13,19). Each year, the seasonal zooplankton blooms, in turn, are followed by cholera outbreaks (11, 13). It has been determined that a single copepod, depending on species and size, can carry up to 10 4 cells of V. cholerae (11,17). Thus, a copepod bloom ca...

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How Vibrio cholerae spreads around the world and what determines its seasonal peaks in endemic areas are not known. These features of cholera have been hypothesized to be primarily the result of environmental factors associated with aquatic habitats that can now be identified. Since 1997, fortnightly surveillance in 4 widely separated geographic locations in Bangladesh has been performed to identify patients with cholera and to collect environmental data. A total of 5670 patients (53% <5 years of age) have been studied; 14.3% had cholera (10.4% due to V. cholerae O1 El Tor, 3.8% due to O139). Both serogroups were found in all locations; outbreaks were seasonal and often occurred simultaneously. Water-use patterns showed that bathing and washing clothes in tube-well water was significantly protective in two of the sites. These data will be correlated with environmental factors, to develop a model for prediction of cholera outbreaks.