Cholera is a bacterial infection that causes diarrhea. The cholera bacterium is usually found in water or food that has been contaminated by feces (poop). Cholera is rare in the US. You may get it if you travel to parts of the world with poor water and sewage treatment. Outbreaks can also happen after disasters. The disease is not likely to spread directly from person to person.

Cholera infections are often mild. Some people don't have any symptoms. If you do get symptoms, they usually start 2 to 3 days after infection. The most common symptom is watery diarrhea.

In some cases, the infection can be severe, causing lots of watery diarrhea, vomiting, and leg cramps. Because you quickly lose body fluids, you are at risk for dehydration and shock. Without treatment, you could die within hours. If you think that you might have cholera, you should get medical care right away.

Doctors diagnose cholera with a stool sample or rectal swab. Treatment is the replacement of the fluid and salts that you lost through the diarrhea. This is usually with a rehydration solution that you drink. People with severe cases may need an I.V. to replace the fluids. Some of them may also need antibiotics. Most people who get fluid replacement right away will recover.

There are vaccines to prevent cholera. One of them is available for adults in the U.S. Very few Americans need it, because most people do not visit areas that have an active cholera outbreak.

There are also simple steps you can take to help to prevent cholera infection:

• Use only bottled or purified water for drinking, washing dishes, making ice cubes, and brushing your teeth
• If you do use tap water, boil it or use iodine tablets
• Wash your hands often with soap and clean water
• Make sure that the cooked food you eat is fully cooked and served hot
• Avoid unwashed or unpeeled raw fruits and vegetables

Cholera is an infection of the small intestines that is caused by the bacterium Vibrio cholera. The condition can range from mild to severe and many affected people may have no obvious signs or symptoms. Approximately 5-10% of infected people will have severe disease with watery diarrhea and vomiting leading to rapid fluid loss, dehydration, and shock. If left untreated, this can cause acute renal failure, severe electrolyte imbalances, coma, or even death. People develop cholera when they eat food or drink water that is contaminated with Vibrio cholera. The condition occurs most often in places that lack water treatment and have poor sanitation and inadequate hygiene. Treatment aims to prevent dehydration and replace the fluids and salts that are lost through diarrhea.

Cholera is an acute intestinal infection causing profuse watery diarrhea, vomiting, circulatory collapse and shock. Many infections are associated with milder diarrhea or have no symptoms at all. If left untreated, 25-50% of severe cholera cases can be fatal.

Frequently Asked Questions

Who gets cholera?

A person can get cholera by drinking water or eating food contaminated with the cholera bacterium. Large epidemics are often related to fecal contamination of water supplies or street vended foods. The disease is occasionally spread through eating raw or undercooked shellfish that are naturally contaminated.

Who is more likely to be exposed to epidemic cholera (toxigenic Vibrio cholerae O1)?

People who are more likely to be exposed to cholera include healthcare personnel treating cholera patients, cholera response workers, and travelers in an area of active cholera transmission who cannot or do not always follow safe food and water precautions and personal hygiene measures.

Who is more likely to have poor outcomes from cholera?

Individuals with achlorhydria (the absence of hydrochloric acid in digestive stomach juices), blood type O, chronic medical conditions, and those without ready access to rehydration therapy and medical services are more likely to have severe disease from cholera and suffer poor outcomes.

Environmental Source

Brackish and marine waters are the natural environment for the etiologic agents of cholera, Vibrio cholerae serogroup O1 or O139. There are no known animal hosts for Vibrio cholerae, however, the bacteria attach themselves easily to the chitin-containing shells of crabs, shrimps, and other shellfish, which can be a source for human infections when eaten raw or undercooked.

About Vibrio cholerae O1 or O139

Epidemic cholera is caused by infection with toxigenic Vibrio cholerae serogroups O1 or O139.

• Only toxigenic strains of serogroups O1 and O139 have caused widespread epidemics and are reportable to the World Health Organization (WHO) as “cholera”.
• V. cholerae O1 has two biotypes, Classical and El Tor, and each biotype has distinct serotypes, Inaba, Ogawa, and rarely Hikojima. The symptoms of infection are indistinguishable, although a higher proportion of persons infected with the El Tor biotype remains asymptomatic or have only a mild illness.
• In recent years, infections with the Classical biotype of Vibrio cholerae O1 have become quite rare and are limited to parts of Bangladesh and India.

Many other serogroups of Vibrio cholerae, with or without the cholera toxin gene, can cause a cholera-like illness, as can non-toxigenic strains of the O1 and O139 serogroups.

Cholera in the U.S.

In the U.S., the occurrence of cholera is very low (0-5 cases per year) and is usually due to ingestion of contaminated food or international travel. There has been a modest increase in imported cases since 1991 related to travel and ongoing epidemics.

Global Cholera Epidemics

Cholera is a major cause of epidemic diarrhea in some parts of the world. For six decades, resource-limited regions in Asia, Africa, and Latin America have faced an ongoing cholera pandemic. In 2017, 34 countries reported an estimated cumulative total of 1.2 million cases, including over 5,600 deaths, to the World Health Organization (WHO). Each year, an estimated 1.3 to 4 million people get cholera and 21,000 to 143,000 die from it worldwide. However, cholera is underreported, and the true burden may be much higher. Most cases continue to occur in resource-limited settings that have unsafe drinking water, poor sanitation, and inadequate hygiene. The African continent has the highest case fatality rates. About 1.3 billion people are at risk of cholera in countries where local transmission occurs.

Global Cholera Challenges

Large population migrations into urban centers in developing countries are straining existing water and sanitation infrastructure and increasing disease risk. Epidemics are a marker for poverty and lack of basic sanitation. Multiple routes exist for spreading cholera, meaning that successful prevention may require different measures in different areas.

Natural infection and currently available vaccines offer incomplete protection of relatively short duration; no multivalent vaccines are available for O139 infections.
Simple rehydration treatment saves lives, but logistics of delivery in remote areas remains difficult during epidemic periods. Accompanying antibiotic treatment is helpful but may be difficult because of growing antimicrobial resistance. Natural reservoirs for the bacterium in warm coastal waters make eradication very unlikely.

Vibrio cholerae is a species of Vibrio bacteria. Some types of Vibrio cholerae bacteria cause serious diarrheal illness called cholera, and others cause illness that’s typically less serious. This page describes infections involving Vibrio cholerae that do not cause cholera.

Questions and Answers

What’s the difference between Vibrio cholerae that cause cholera and those that don’t?

Two serogroups (O1 and O139) or types of Vibrio cholerae bacteria can produce cholera toxin that causes the disease we call cholera. About 1 in 10 people infected with cholera toxin-producing O1 or O139 Vibrio cholerae experience severe, life-threatening illness, and both serogroups can cause widespread epidemics. Learn about this severe, life-threatening illness and the serogroups that cause it.

All other Vibrio cholerae types are known as “non-cholera Vibrio cholerae.” These include strains of Vibrio cholerae O1 and O139 that do not produce cholera toxin. Most illnesses these bacteria cause are mild, and these bacteria do not cause epidemics.

How do people become infected?

Like Vibrio species that cause vibriosis, non-cholera Vibrio cholerae bacteria naturally live in coastal waters and are present in higher concentrations when water temperatures are warmer. Most infections occur during warm weather.

In the United States, most people become infected by eating raw or undercooked shellfish, particularly oysters. The bacteria also can cause an infection when an open wound is exposed to salt water or brackish water, which is a mixture of fresh and salt water that’s often found where rivers meet the sea. Learn about other Vibrio species that can cause diarrheal illness and wound infection.

Casual contact with an infected person does not put someone at risk of infection.

What are the symptoms of infection?

• Most people experience diarrhea, which can range from mild to severe and watery.
• Some people experience fever.
• People with a wound infection may experience redness and swelling at the infection site.

How is infection diagnosed?

A doctor may suspect Vibrio infection if a patient has diarrhea and has recently eaten raw or undercooked seafood, especially oysters, or when a wound infection has developed after a wound was in contact with salt water or brackish water.

Infection is diagnosed when Vibriocholerae bacteria that do not produce cholera toxin are found in a sample of the stool, in a wound, or in the blood of the patient.

How is infection treated?

People with diarrhea should drink plenty of liquids to replace lost fluids.

Most people with non-cholera Vibrio cholerae infection recover without antibiotic treatment within a few days. However, antibiotics are sometimes used to treat people with these Vibrio infections, including people with severe or prolonged illness, those at risk of severe illness, and those with a wound infection.

Who is more likely to get an infection or severe illness?

Anyone can become infected, but those at increased risk of infection or severe illness include those who:

• Have liver disease, cancer, diabetes, HIV, or thalassemia (an inherited blood disorder)
• Receive immune-suppressing therapy for the treatment of disease
• Take medicine to decrease stomach acid levels
• Have had stomach surgery

How can infection be prevented?

The following tips can help reduce your chance of infection:

• Do not eat raw or undercooked shellfish, such as oysters.
• If you have a wound, you should avoid contact with salt water, brackish water or seafood juices from wading, fishing, or cleaning seafood. If you cannot avoid these potential exposures, cover your wound with a waterproof bandage.
• You should wash wounds with soap and water as soon as possible if they are exposed to salt water, brackish water, raw seafood, or raw seafood juices.

How common is infection?

Non-cholera Vibrio cholerae are the third most commonly reported group of Vibrio bacteria causing infection in the United States, with about 100 cases reported each year. Many more cases, however, are likely not diagnosed or reported.

Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae and is spread by ingestion of contaminated food or water. The infection is often mild or without symptoms, but sometimes it can be severe and life threatening.

Approximately one in ten (5-10%) of infected persons will have severe cholera which in the early stages includes:

• profuse watery diarrhea, sometimes described as “rice-water stools,”
• vomiting
• rapid heart rate
• loss of skin elasticity
• dry mucous membranes
• low blood pressure
• thirst
• muscle cramps
• restlessness or irritability

Health care providers should look for signs of dehydration when examining a patient with profuse watery diarrhea. These include:

• rapid heart rate
• loss of skin elasticity
• dry mucous membranes
• low blood pressure

People with severe cholera can develop severe dehydration, which can lead to kidney failure. If left untreated, severe dehydration can lead to shock, coma, and death within hours.

Person washing hands over a bucket of water.

The profuse diarrhea produced by cholera patients contains large amounts of the infectious Vibrio cholerae germ that can infect others if swallowed. This can happen when the bacteria get on food or into water.

To prevent the bacteria from spreading, all feces (human waste) from sick persons should be thrown away carefully to ensure it does not contaminate anything nearby.

People caring for cholera patients must wash their hands thoroughly after touching anything that might be contaminated with patients’ feces (poop).

When cholera patients are treated quickly, they usually recover without long-term consequences. Cholera patients do not typically become carriers of the cholera bacteria after they recover, but they get sick if exposed again.

It is almost impossible to distinguish a single patient with cholera from a patient infected by another pathogen that causes acute watery diarrhea without testing a stool sample. A review of clinical features of multiple patients who are part of a suspected outbreak of acute watery diarrhea can be helpful in identifying cholera because of the rapid spread of the disease.

While management of patients with acute watery diarrhea is similar regardless of the illness, it is important to identify cholera because of the potential for a widespread outbreak.

How to Diagnose

Isolation and identification of Vibrio cholerae serogroup O1 or O139 by culture of a stool specimen remains the gold standard for the laboratory diagnosis of cholera.

Cary Blair media is ideal for transport, and the selective thiosulfate–citrate–bile salts agar (TCBS) is ideal for isolation and identification. Reagents for serogrouping Vibrio cholerae isolates are available in all state health department laboratories in the U.S. Commercially available rapid test kits are useful in epidemic settings but do not yield an isolate for antimicrobial susceptibility testing and subtyping, and should not be used for routine diagnosis.

In many countries where cholera is not uncommon, but access to diagnostic laboratory testing is difficult, WHO recommends the following clinical definition be used for suspected cholera cases.

Suspected cholera case

• In areas where a cholera outbreak has not been declared: Any patient 2 years old or older presenting with acute watery diarrhea and severe dehydration or dying from acute watery diarrhea.
• In areas where a cholera outbreak is declared: any person presenting with or dying from acute watery diarrhea.

WHO also recommends the following definition for confirmed cholera cases.

Confirmed cholera case

A suspected case with Vibrio cholerae O1 or O139 confirmed by culture or PCR and, in countries where cholera is not present or has been eliminated, the Vibrio cholerae O1 or O139 strain is demonstrated to be toxigenic.

Rapid Tests

In areas with limited or no laboratory testing, the Crystal^® VC dipstick rapid test can provide an early warning to public health officials that an outbreak of cholera is occurring. However, the sensitivity and specificity of this test is not optimal. Therefore, it is recommended that fecal specimens that test positive for V. cholerae O1 and/or O139 by the Crystal^® VC dipstick always be confirmed using traditional culture-based methods suitable for the isolation and identification of V. cholerae.

Detection in the U.S.

Cholera is a nationally reportable disease in the U.S. All isolates should be sent to CDC via state health department laboratories for cholera toxin-testing and subtyping.

Most persons infected with the cholera bacterium have mild diarrhea or no symptoms at all. Only a small proportion, about 10%, of persons infected with Vibrio cholerae O1 may have illness requiring treatment at a health center. Cholera patients should be evaluated and treated quickly. With proper treatment, even severely ill patients can be saved.

• Rehydration therapy, the primary treatment for cholera patients, refers to the prompt restoration of lost fluids and salts.
• Antibiotic treatment reduces fluid requirements and duration of illness, and is indicated for severe cases of cholera.
• Zinc treatment has also been shown to help improve cholera symptoms in children.

Cholera can cause dehydration, which can be deadly if not properly treated. With timely rehydration therapy, more than 99% of cholera patients will survive. That’s why rehydration is the most important treatment for cholera.

Rehydration therapy for patients with cholera can include

• adequate volumes of a solution of oral rehydration salts,
• intravenous (IV) fluids when necessary, and
• electrolytes.

When patients with cholera are not treated with rehydration therapy, at least 1 in 4 to close to half of them can die from the disease.

Key Points About Rehydration

• Rapid high-volume rehydration will save lives
• Many patients can be rehydrated entirely with oral rehydration solution ORS)
• Even if the patient gets intravenous (IV) rehydration, he/she should start drinking ORS as soon as he/she is able

Signs and Symptoms of Dehydration

Severe Dehydration
One or more danger signs:

• Lethargic or unconscious
• Absent or weak pulse
• Respiratory distress

OR at least two of the following:

• Sunken eyes
• Not able to drink or drinks poorly
• Skin pinch goes back very slowly

Some Dehydration
No danger signs AND at least two of the following:

• Irritable or restless
• Sunken eyes
• Rapid pulse
• Thirsty (drinks eagerly)
• Skin pinch goes back slowly

No Dehydration
Signs:

• Awake and alert
• Normal pulse
• Normal thirst
• Eyes not sunken
• Skin pinch normal

Rehydration

Oral Rehydration Guidance: No to Some Dehydration

• Give oral rehydration solution (ORS) immediately to dehydrated patients who can sit up and drink. If ORS is not available, you should provide water, broth, and/or other fluids. You should not provide drinks with a high sugar content, such as juice, soft drinks, or sports drinks, because they could worsen diarrhea.
• Offer ORS frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus.
• Give small, frequent sips of ORS to patients who vomit, or give ORS by nasogastric tube.
  • Make ORS with safe water, which is water that has been boiled or treated with household bleach or a chlorine product using the dose recommended in the product’s instructions, at least 15 minutes before adding prepackaged oral rehydration salts. To make the solution, mix the oral rehydration salts (a prepackaged sachet of glucose and electrolytes) with 1 liter of safe water.
• A rough estimate of oral rehydration rate for older children and adults is 100 ml of ORS every 5 minutes, until the patient stabilizes.
• The approximate amount of ORS (in milliliters) needed over 4 hours can also be calculated by multiplying the patient’s weight in kg by 75.
• If the patient requests more than the prescribed ORS solution, give more.
• Patients should continue to eat a normal diet or resume a normal diet once vomiting stops.
• For infants: encourage the mother to continue breastfeeding.

Assessment

• Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
• During the initial stages of therapy, while still dehydrated, adults can consume as much as 1,000 ml of ORS per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
• The volumes and time shown are guidelines based on usual needs. If necessary, you can increase the amount and frequency, or you can give the ORS solution at the same rate for a longer period to achieve adequate rehydration. Similarly, you can decrease the amount of fluid if the patient becomes hydrated earlier than expected.

Intravenous Rehydration Guidance: Severe Dehydration or Shock

• Patients should receive intravenous (IV) rehydration if they have
  • severe dehydration,
  • stupor,
  • coma,
  • uncontrollable vomiting, or
  • extreme fatigue that prevents drinking.
• For severe dehydration, start IV fluids immediately. If the patient can drink, give ORS by mouth while the IV drip is set up. Ringer’s lactate IV fluid is preferred. If not available, use normal saline or dextrose solution.
• It is important to measure the amount of IV fluids delivered and measure the fluid lost as diarrhea and vomitus.

Assessment

• Reassess the patient every 15–30 minutes and continue hydrating. The volumes and time intervals shown are guidelines provided on the basis of usual needs.
  • If necessary, you can increase the rate of fluid administration, or you can give the fluid at the same rate for a longer period, to achieve adequate rehydration. If hydration is not improving, give fluids more rapidly; the patient may need 200 ml/kg or more of intravenous fluids during the first 24 hours of treatment.
  • You can decrease the amount of fluid if the patient becomes hydrated earlier than expected.
  • Give more than the prescribed ORS solution if the patient requests more.
• Switch from intravenous hydration to oral rehydration solution once hydration is improved and the patient can drink. This will conserve IV fluids and reduce the risk of phlebitis and other complications.
  • You can use nasogastric tubes to administer oral rehydration solution if the patient is alert but unable to drink sufficient quantities independently.

Fluid Replacement or Treatment Recommendations

*Repeat once if radial pulse is still very weak or not detectable

Signs of Adequate Rehydration

• Skin goes back normally when pinched
• Thirst has subsided
• Urine has been passed
• Pulse is strong

Special Populations

Patients with severe acute malnutrition

Patients with severe acute malnutrition should receive oral rehydration with low-osmolarity ORS instead of the standard rehydration solution for diarrhea, ReSoMal, which does not have sufficient sodium content to replace the losses from cholera. More information is available in WHO’s guidelines for inpatient treatment of severely malnourished infants and children. Breastfed infants should continue to breastfeed. If ORS is not available, provide water, broth, and/or other fluids; avoid fluids high in sugar, such as juice, soft drinks, and sports drinks.

Pregnant women

Pregnant women with cholera are at a higher risk of fetal loss compared with the general population of pregnant women, and dehydration should be treated promptly. Dehydration can be difficult to assess and may be underestimated during the later stages of pregnancy. Closely monitor the patient’s degree of dehydration, response to treatment, and systolic blood pressure.

Recommendations for the Use of Antibiotics for the Treatment of Cholera

Summary Recommendations

1. Oral or intravenous hydration is the primary treatment for cholera.
2. In conjunction with hydration, treatment with antibiotics is recommended for severely ill patients. It is also recommended for patients who have severe or some dehydration and continue to pass a large volume of stool during rehydration treatment. Antibiotic treatment is also recommended for all pregnant women and patients with comorbidities (e.g., severe acute malnutrition, HIV infection).
3. Antibiotics are given as soon as the patient can tolerate oral medication. The choice of antibiotic should be informed by local antibiotic susceptibility patterns. In most countries, doxycycline is recommended as first-line treatment for adults (including pregnant women) and children. If resistance to doxycycline is documented, azithromycin and ciprofloxacin are alternative options.
4. During an epidemic or outbreak, antibiotic susceptibility should be monitored through regular testing of sample isolates from various geographic areas.
5. None of the guidelines recommend antibiotics as prophylaxis for cholera prevention, and all emphasize that antibiotics should be used in conjunction with aggressive hydration.
6. Education of healthcare workers, assurance of adequate supplies, and monitoring of practices are all important for appropriate dispensation of antibiotics.

Background

1. Cholera treatment is hydration
   Intravenous and oral hydration are both associated with greatly decreased mortality and remain the mainstay of treatment for cholera.
2. Antibiotic effectiveness for the treatment of cholera
   • Antibiotics have been used as an adjunct to hydration treatment for cholera since 1964. Findings from randomized controlled trials evaluated the effectiveness of selected antibiotics on three main outcomes: stool output, duration of diarrhea, and bacterial shedding. These studies compared outcomes for cholera patients who were given both intravenous (IV) fluids and antibiotic treatment with those given IV fluids only. Findings indicate that antibiotics reduced volume of stool output by 8–92%, duration of diarrhea by 50–56%, and duration of positive bacterial culture by 26–83%.
   • To help reduce resource requirements, consider using antibiotics for patients who are seriously dehydrated or have some dehydration with continued net fluid loss despite rehydration. By decreasing duration of diarrhea and volume of stool, antibiotics result in more rapid recovery and shorter lengths of inpatient stay, both of which contribute to more efficient use of resources during an outbreak.
   • The majority of published studies that explore effectiveness of antibiotics for cholera patients were done in patients who were adequately rehydrated. In these studies, there was no mortality, and therefore, the impact of antibiotics on mortality could not be assessed. In the absence of adequate rehydration, antibiotics alone are not sufficient to prevent cholera mortality.
3. Antibiotic regimens for the treatment of cholera
   Tetracycline has been shown to be an effective treatment for cholera and is superior to furazolidone, cholamphenicol,and sulfaguanidine in reducing cholera morbidity. Treatment with a single 300-mg dose of doxycycline has been shown to be equivalent to tetracycline treatment and is now recommended as first-line treatment in adults, including pregnant women, and in children. Previously, antibiotics of the tetracycline class were not recommended for pregnant women due to teratogenic effects, or in children due to dental discoloration. In a recent systematic review among pregnant women and young children receiving doxycycline, there was no correlation between the use of doxycycline and teratogenic effects or dental staining in children. Erythromycin is effective for cholera treatment and is also an appropriate alternative regimen for adults, including pregnant women, and children. Norfloxacin, trimethoprim-sulfamethoxazole (TMP-SMX), and ciprofloxacin are effective, but doxycycline offers advantages related to ease of administration and comparable or superior effectiveness. Recently, azithromycin has been shown to be more effective than erythromycin and ciprofloxacin.Resistance to tetracycline and other antimicrobial agents among Vibrio cholerae has been demonstrated in both endemic and epidemic cholera settings. Resistance can result from the accumulation of selected mutations over time, or from the acquisition of genetic elements such as plasmids, introns, or conjugative elements, which confer rapid spread of resistance. A likely risk factor for antimicrobial resistance is widespread use of antibiotics, including mass distribution for prophylaxis in asymptomatic individuals. Antibiotic resistance emerged in previous epidemics in the context of antibiotic prophylaxis for household contacts of cholera patients.
4. Unanswered questions
   Inadequate information still exists with respect to antibiotics in the following areas:
   1. Effect of antibiotics on secondary transmission
      • There are insufficient data examining the effect of antibiotics on secondary transmission of cholera. However, in published studies to date, antibiotics have not been shown to decrease secondary transmission of cholera within households.
   2. Utility of antibiotics when aggressive rehydration is not possible
      • Because studies on antibiotic treatment for cholera were conducted in patients who received adequate rehydration, the effect of antibiotics in settings where this is not possible remains unclear.
5. Summary of antibiotic treatment recommendations
   Antibiotics are recommended in cholera-infected patients with serious dehydration, or moderate dehydration with continuing net fluid losses despite rehydration. Antibiotics should not be used as prophylaxis for cholera prevention (except in specific institutional settings, such as prisons or psychiatric institutions), and should be used in conjunction with aggressive hydration 21. In addition, antimicrobial susceptibility testing should inform local drug choices. Antibiotic administration recommendations are provided below. Table showing the recommendations for Cholera treatment with antibiotics

   Age group	First-line drug choice	Alternate drug choices
   Children <12 years old	Doxycycline 2–4 mg/kg by mouth (per os, p.o.) single dose	Azithromycin 20 mg/kg (max 1 g) p.o. single dose, or ciprofloxacin 20 mg/kg (max 1 g) p.o. single dose
   Childen ≥12 years old and adults, including pregnant women	Doxycycline 300 mg p.o. single dose	Azithromycin 1 g p.o. single dose, or ciprofloxacin 1 g p.o. single dose

   * Please note, due to space constraints, dosage information is not included in this table. Dosage treatment guidance can be found on WHO’s cholera outbreak response website.

6. Considerations
   • Do not over-emphasize antibiotic treatment of cholera at the expense of the recommended primary treatment of oral and intravenous rehydration.
   • Doxycycline costs approximately $0.02 per 100-mg tablet. Azithromycin costs approximately $0.16 per 250-mg tablet.
   • Antibiotics can cause nausea and vomiting. Gastrointestinal side effects should be carefully monitored, especially in dehydrated patients.
   • In general, antibiotics should not be given to cholera patients with only some or no diarrhea and/or dehydration.
   • Prospective surveillance for antibiotic resistance among bacterial isolates from any outbreak is essential for understanding and minimizing the spread of resistance.

When available, supplementation (20 mg zinc per day in children 6 months or older) should be started immediately.

A study in Bangladesh showed that zinc supplementation significantly reduced the duration and severity of diarrhea in children suffering from cholera. The study was conducted with 179 children, 3-14 years old, who were admitted to a hospital within 24 hours of the onset of cholera symptoms. In the study, all children received antibiotics and rehydration therapy as needed, but those in the intervention group also received zinc supplementation. Children who received zinc supplementation had 8 fewer hours of diarrheal illness and 10% less diarrheal stool volume, on average. Zinc has also been shown to have a similar effect in children with diarrhea caused by infections other than cholera, and is recommended for the treatment of pediatric diarrhea more generally.

ORS-zinc co-pack is now included in the World Health Organization’s updated essential medicines lists.

Note: administering zinc with certain antibiotics, such as ciprofloxacin, may reduce the absorption of these antibiotics. In these circumstances administer antibiotics 2 hrs before or 4-6 hrs after zinc.

If you live in or are visiting an area where cholera is occurring or has occurred, be aware of basic cholera facts and follow the five cholera prevention tips listed below. These tips will help you protect yourself and your family.

To prevent cholera, you should wash your hands often and take precautions to ensure your food and water are safe for use. The risk for cholera is very low for people visiting areas with epidemic cholera when these simple steps are followed:

1. Make sure to drink and use safe water to brush your teeth, wash and prepare food, and make ice

• It is safe to drink and use bottled water with unbroken seals, and canned or bottled carbonated beverages.
• If bottled water is not available, use water that has been properly boiled, chlorinated, or filtered:
  • Boiling is the most effective way to make water safe. If boiling, bring your water to a complete boil for at least 1 minute.
  • If boiling is not possible, you can use a chlorine product (i.e., granules or product tablets) to make your water safe. To treat your water with chlorine granules or tablets, use one of the locally available treatment products and follow the instructions.
  • If a chlorine treatment product is not available, you can treat your water with household bleach.
  • Always store your treated water in a clean, covered container.
• Clean food preparation areas and kitchenware with soap and safe water and let them dry completely before reuse.
  • Piped water sources, drinks sold in cups or bags, and ice may not be safe. If you suspect your water may not be safe, boil or treat it with a chlorine product.

2. Wash your hands often with soap and safe water*

• Before, during, and after preparing food for yourself or your family
• After using the latrine or toilet
• After cleaning your child’s bottom
• Before and after caring for someone with cholera

Follow the five steps to washing hands the right way:

• Wet your hands with clean water.
• Apply soap to your hands and rub them together. Be sure to lather the back of your hands, between your fingers, and under your nails.
• Scrub your hands for at least 20 seconds.
• Rinse your hands well under clean water.
• Allow your hands to air dry or dry them with a clean towel.

* If proper handwashing resources are not available, wash your hands using water that is as clean as possible (e.g. that’s not visibly cloudy) from a safe source (e.g., an improved source like a borehole or protected spring).

Traveling to an area with cholera?

The FDA approved a single-dose live oral cholera vaccine called Vaxchora^®. Vaxchora is recommended to prevent infection in adults who are 18 – 64 years old and are traveling to an area of active cholera transmission with toxigenic Vibrio cholerae O1 (the bacteria strain that most commonly causes cholera).

3. Use latrines or bury your poop; do not poop in any body of water

• Use latrines or other sanitation systems, like chemical toilets, to dispose of poop.
• Wash hands with soap and safe water after pooping.
• Clean latrines and surfaces contaminated with poop using a solution of 1 part household bleach to 9 parts water.

What if I don’t have a latrine or chemical toilet?

• Poop at least 30 meters (approximately 100 feet) away from any body of water and then bury your poop.
• Dispose of plastic bags that contain poop by putting them in latrines or at collection points, if available. You can also bury them in the ground. Do not put plastic bags in chemical toilets.
• Dig new latrines or temporary pit toilets at least a half-meter (approximately 1 ½ feet) deep and at least 30 meters (approximately 100 feet) away from any body of water.

4. Cook food well (especially seafood), keep it covered, and eat it hot. Peel fruits and vegetables*

• Be sure to cook shellfish (like crabs and crayfish) until they are very hot all the way through.
• *Avoid raw foods other than fruits and vegetables that you have peeled yourself.

5. Clean up safely in the kitchen and in places where the family bathes and washes clothes

• Wash yourself, your children, diapers, and clothes, 30 meters (approximately 100 feet) away from drinking water sources.

• Drink and use safe water
• Cook food thoroughly
• Wash hands with soap and safe water after caring for the patients, and especially after handling poop
• Remove and wash any bedding or clothing that may have had contact with diarrhea, preferably in a washing machine using warm or hot water. Usual machine detergents are sufficient; bleach is not necessary.
• Use a flush toilet or approved septic system; double bag soiled materials (items contaminated with poop) when throwing them away.
• Use any household disinfectant or a bleach solution made up of 1 part bleach to 9 parts water to clean any area that may have contact with poop, including the patient’s bathroom, bedpan, as soon as possible after being soiled.
• When possible, use rubber gloves when cleaning any room or surface that may have had contact with the patient’s poop.
• Patients with cholera should not swim until their symptoms have been gone for 2 weeks.
• If another household member starts having diarrhea, give themoral rehydration solution (ORS) and go to a healthcare provider immediately.
• While caring for persons who are sick with cholera, do not serve food or drink to anyone outside of the household.
• Any visitors should be very careful to avoid touching contaminated surfaces and should wash hands thoroughly before leaving and again when they arrive at their next destination.

Healthcare providers should take precautions to prevent the spread of cholera in clinical settings:

• Chemoprophylaxis with antibiotics is not indicated for healthcare providers
• All staff should be trained on cholera prevention and infection control measures, such as handwashing and safe disposal of human waste
• Handwashing with soap and clean water or 0.05% chlorine should be done before and after each patient contact
  • If soap and water are not available, use an alcohol-based hand sanitizer with at least 60% alcohol, or if neither are available, 0.05% chlorine solution
• Several chlorine solutions can be used for surface disinfection (solution calculations are based on using unscented household bleach with 5–6 % active chlorine):
  • 2% chlorine
    • Made by mixing 3 parts water and 2 parts bleach (or 400 ml of bleach in 1 litre of water)
    • Used for disinfecting vomit, feces, and corpses
  • 0.2% chlorine
    • Made by mixing 9 parts water and 1 part bleach (or 40 ml of bleach in 1 litre of water)
    • Used for cleaning floors, boots, personal protective equipment (gloves, aprons, goggles), bedding, latrines, dishes
  • 0.05% chlorine
    • Made by mixing 9 parts water and 1 part 0.5% chlorine solution (or 10 ml of bleach in 1 litre of water)
    • Used for bathing soiled patients, handwashing, laundry

Vaxchora^® (lyophilized CVD 103-HgR)

Please note: In December 2020, the maker of this cholera vaccine will temporarily stop making and selling it. This vaccine may be in limited supply or unavailable.

The FDA recently approved a single-dose live oral cholera vaccine called Vaxchora^® (lyophilized CVD 103-HgR) in the United States. The Advisory Committee on Immunization Practices (ACIP) voted to approve the vaccine for adults 18 – 64 years old who are traveling to an area of active cholera transmission.

• An area of active cholera transmission is defined as a province, state, or other administrative subdivision within a country where cholera infections may be reported regularly (endemic) or where a cholera outbreak is occurring (epidemic), and includes areas with cholera activity within the past year.
• The vaccine is not regularly recommended for most travelers from the United States, as most travelers do not visit areas with active cholera transmission.
• No country or territory currently requires vaccination against cholera as a condition for entry.

Vaxchora^® has been reported to reduce the chance of severe diarrhea in people by 90% at 10 days after vaccination and by 80% at 3 months after vaccination. The safety and effectiveness of Vaxchora^® in pregnant or breastfeeding women is not yet known, and it is also not known how long protection lasts beyond 3 – 6 months after getting the vaccine. Side effects from Vaxchora^® are uncommon and may include tiredness, headache, abdominal pain, nausea and vomiting, lack of appetite, and diarrhea.

Dukoral^®, ShanChol^®, and Euvichol-Plus^®/Euvichol^®

Three other oral inactivated, or non-live cholera vaccines are available: Dukoral (manufactured by SBL Vaccines); ShanChol (manufactured by Shantha Biotec in India), and Euvichol-Plus/Euvichol (manufactured by Eubiologics). These cholera vaccines are World Health Organization (WHO) prequalified, but are not available in the U.S.

Cholera vaccines offer incomplete protection. Therefore, vaccination should never take the place of standard prevention and control measures.

What is cholera?

Cholera is a disease caused by bacteria called Vibrio cholerae. Cholera bacteria spread from one person to another in places where sanitation is poor and there is limited access to safe drinking water.

You can get sick with cholera by drinking water or eating food contaminated with cholera bacteria. Cholera symptoms include diarrhea, nausea, dizziness, and vomiting. People with severe cholera have large amounts of watery diarrhea. Often described as “rice-water stool,” cholera diarrhea can have a pale, milky appearance. Cholera can lead to death if a person becomes dehydrated from loss of fluids and electrolytes.

Who is at risk?

Most international travelers do not get cholera because they do not visit areas with active cholera transmission and usually have good access to safe food and water.

Cholera is found in countries around the world but is extremely rare in the United States and other industrialized nations.

The following is a list of countries that have areas of active cholera transmission

• Africa: Benin, Cameroon, Democratic Republic of the Congo, Ethiopia, Kenya, Malawi, Mozambique, Niger, Nigeria, Somalia, South Sudan, Tanzania, Uganda
• Asia: Afghanistan, Bangladesh, India, Nepal, Philippines, Yemen
• Americas: none
• Pacific: none

What can travelers do to prevent cholera?

Travelers can protect themselves against cholera, even travelers going to areas of active cholera transmission, by taking the following steps:

Choose food and drinks carefully

• Only eat foods that are cooked and served hot
• Avoid food that has been sitting on a buffet
• Eat raw fruits and vegetables only if you have washed them in clean water or peeled them
• Only drink beverages from factory-sealed containers
• Avoid ice because it may have been made from unclean water
• Drink pasteurized milk

Wash hands carefully

• Wash hands often with soap and water for 20 seconds, especially after using the bathroom and before eating
• If soap and water aren’t available, use an alcohol-based hand sanitizer that contains at least 60% alcohol
• Keep your hands away from your face and mouth

A licensed cholera vaccine called Vaxchora® (lyophilized CVD 103-HgR, Emergent BioSolutions) is available in the United States for adults 18-64 years old. It prevents severe diarrhea caused by the most common types of cholera-causing bacteria. Most U.S. travelers don’t get vaccinated because very few visit areas with active cholera.

Adults traveling to countries that have areas of active cholera transmission should ask their healthcare provider the following questions when considering the vaccine:

• How common is cholera in the specific area where I am going?
• How common is cholera infection among travelers going to this area?
• Which activities may put me at risk for cholera?
• Will I be able to receive rapid treatment (if needed) at my destination?

How is cholera treated?

The most important step in treating cholera is to replace lost body fluids (rehydration). Antibiotics can shorten the length of illness and help prevent fluid loss (dehydration) in people with severe cholera. Zinc treatment has also been shown to help improve cholera symptoms in children.

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider, and tell them about your travel. Avoid contact with other people while you are sick.

What is cholera?

Cholera is an acute, diarrheal illness caused by infection of the intestine with the toxigenic bacterium Vibrio cholerae serogroup O1 or O139. An estimated 2.9 million cases and 95,000 deaths occur each year around the world. The infection is often mild or without symptoms, but can sometimes be severe. Approximately one in 10 (10%) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.

Where is cholera found?

The cholera bacterium is usually found in water or food sources that have been contaminated by feces (poop) from a person infected with cholera. Cholera is most likely to be found and spread in places with inadequate water treatment, poor sanitation, and inadequate hygiene.

The cholera bacterium may also live in the environment in brackish rivers and coastal waters. Shellfish eaten raw have been a source of cholera, and a few persons in the U.S. have contracted cholera after eating raw or undercooked shellfish from the Gulf of Mexico.

How does a person get cholera?

A person can get cholera by drinking water or eating food contaminated with the cholera bacterium. In an epidemic, the source of the contamination is usually the feces of an infected person that contaminates water and/or food. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water. The disease is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk for becoming ill.

What are the symptoms of cholera?

Cholera infection is often mild or without symptoms, but can sometimes be severe. Approximately one in ten (10%) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.

How long after infection do the symptoms appear?

It usually takes 2-3 days for symptoms to appear after a person ingests cholera bacteria, but the time can range from a few hours to 5 days.

Who is most likely to get cholera?

Persons living in places with unsafe drinking water, poor sanitation, and inadequate hygiene are at the highest risk for cholera.

What should I do if I or someone I know gets sick?

If you think you or a member of your family might have cholera, seek medical attention immediately. Dehydration can be rapid so fluid replacement is essential. If you have oral rehydration solution (ORS), start taking it immediately; it can save a life. Continue to drink ORS at home and while traveling to get medical treatment. If an infant has watery diarrhea, continue breastfeeding.

How is cholera diagnosed?

To test for cholera, doctors must take a stool sample or a rectal swab and send it to a laboratory to look for the cholera bacteria.

What is the treatment for cholera?

Cholera can be simply and successfully treated by immediate replacement of the fluid and salts lost through diarrhea. Patients can be treated with oral rehydration solution (ORS), a prepackaged mixture of sugar and salts to be mixed with 1 liter of water and drunk in large amounts. This solution is used throughout the world to treat diarrhea. Severe cases also require intravenous fluid replacement. With prompt appropriate rehydration, fewer than 1% of cholera patients die.

Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as receiving rehydration. Persons who develop severe diarrhea and vomiting in countries where cholera occurs should seek medical attention promptly.

Should I be worried about getting cholera from others?

The disease is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk for becoming ill.

How can I avoid getting cholera?

Be aware of whether cholera cases have recently occurred in an area you plan to visit. However, the risk for cholera is very low for people visiting areas with epidemic cholera when simple prevention steps are taken.

All visitors or residents in areas where cholera is occurring or has occurred should follow recommendations to prevent getting sick:

• Drink only bottled, boiled, or chemically treated water and bottled or canned beverages. When using bottled drinks, make sure the seal has not been broken. Carbonated water may be safer than non-carbonated water. Avoid tap water, fountain drinks, and ice cubes.
• To disinfect your own water, choose one of the following options:
  • Boil it for 1 minute, or
  • Filter it and add either ½ an iodine tablet or 2 drops of household bleach per liter/quart of water, or
  • Use commercial water chlorination tablets according to the manufacturer’s instructions.
• Wash your hands often with soap and clean water, especially before you eat or prepare food and after using the bathroom.
  • If no water and soap are available, use an alcohol-based hand sanitizer with at least 60% alcohol.
• Use bottled, boiled, or chemically treated water to wash dishes, brush teeth, wash and prepare food, and make ice.
• Eat foods that are packaged or that are freshly cooked and served hot.
  • Do not eat raw or undercooked meats and seafood, or raw or undercooked fruits and vegetables unless they are peeled.
• Dispose of feces in a sanitary manner to prevent contamination of water and food sources.

Is a vaccine available to prevent cholera?

The FDA recently approved a single-dose live oral cholera vaccine called Vaxchora® (lyophilized CVD 103-HgR) for adults 18 – 64 years old who are traveling to an area of active cholera transmission with toxigenic Vibrio cholerae O1 (the bacteria strain that most commonly causes cholera). The vaccine is not routinely recommended for most travelers from the United States, as most people do not visit areas of active cholera transmission. Three other oral inactivated, or non-live cholera vaccines, Dukoral®, ShanChol®, and Euvichol-Plus®/Euvichol® are World Health Organization (WHO) prequalified, but these vaccines are not available in the U.S. No cholera vaccine is 100% protective and vaccination against cholera is not a substitute for standard prevention and control measures, including precautions for food and water as outlined above.

What is the risk for cholera in the U.S.?

• Cholera was prevalent In the United States in the 1800s but water-related spread has been eliminated by modern water and sewage treatment systems. Very rarely, people in the U.S. get sick with cholera after eating raw or undercooked shellfish from the Gulf of Mexico.
• However, U.S. travelers to areas with epidemic cholera (for example, parts of Africa, Asia, and Latin America) can be exposed to cholera bacteria, and might develop illness after arriving home. Some travelers have brought contaminated seafood home from abroad, resulting in cholera.