Overview

Cholera is an intestinal infection caused by the bacterium Vibrio cholerae (V. cholerae)  that has the potential to kill within hours.1,2

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The most common source of transmission is through ingestion of food and water that has been contaminated with fecal matter from cholera-infected persons.3

Cholera is most likely to be found in areas where there is inadequate water treatment, poor sanitation, and insufficient hygiene.3

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Why This Ancient Disease Matters Now

Throughout history, populations around the world have been sporadically affected by devastating outbreaks of cholera.5

A persistent pathogen: brief history of cholera

 

Cholera Is Where You Expect It...

Cholera is estimated to be endemic in 69 countries, primarily in Africa, Asia, and the Caribbean.16

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  • Dominican Repubilic

  • Jamaica

  • People's Republic of China

  • India

  • Philippines16,17

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...and Where You Don't

Recent cases also demonstrate travelers can get cholera
in countries that are not considered endemic, including popular tourist destinations like

Cuba & Thailand.19-22 choleraUnd190

Case Report

In 2013, an Italian tourist spent 2 weeks in Havana, Cuba. He did not seek medical advice prior to travel. During his stay, he drank tap water, ate local fruits and vegetables washed with tap water, and ate raw seafood he caught himself on the coast of Havana. The tourist did not report direct contact with sick individuals while on his trip.21

Symptoms included watery diarrhea, severe weakness, tachycardia, muscle cramps, dizziness, abdominal pain, nausea, and vomiting.

The traveler was admitted to the hospital for diarrhea, dehydration, a 10-kg weight loss, hypotension, and severe oligoanuric renal failure.

Treatment with IV rehydration and antibiotics was required.

 

Symptoms

Symptoms typically appear in 2 to 3 days, but disease onset may vary from a few hours to up to 5 days after exposure to the bacterium.1

A characteristic symptom is sudden voluminous explosive diarrhea.2 Individuals infected with cholera exhibit a range of clinical manifestations. Some are asymptomatic or have only mild diarrhea; others present with the sudden onset of explosive and life-threatening diarrhea (cholera gravis).7

 
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Among people developing symptoms23:

  • 80% present with mild to moderate symptoms including acute watery diarrhea

  • 20% develop severe disease
    (cholera gravis) that could be fatal

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Cholera by the Hour

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This case demonstrates how quickly the disease can progress and that even early recognition of the disease and antibiotic treatment did not prevent the physician from requiring rapid transport to a hospital for treatment with IV rehydration.24

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Highly Underreported and Underdiagnosed

In the US, the CDC estimates the true number of cholera cases to be as much as 33 times higher than that observed by national surveillance systems.27

For travelers to endemic regions, the estimated rate of contracting cholera is higher than that of many other vaccine-preventable travel diseases including28:

  • Japanese encephalitis

  • Meningococcal disease

  • Rabies

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A Toxin-Mediated Disease

After ingestion of a large enough dose of bacteria that are able to survive gastric acidity, V. cholerae  colonizes mucosal cells of the small intestine.

Once established, V. cholerae  releases cholera toxin, which binds to small intestine epithelial cells.

The cholera toxin consists of a single enzymatic component (the A subunit) and a pentameric binding component (the B subunit). The release of the A subunit stimulates the enzyme system of intestinal cells, leading to an increase in chloride secretion by crypt cells.

This in turn leads to inhibition of absorption of sodium and chloride by the microvilli. These events cause massive purging of electrolyte-rich fluid into the small intestine that exceeds the absorptive capacity of the colon, resulting in rapid dehydration and depletion of electrolytes including sodium, chloride, bicarbonate, and potassium.3,7,21

Pathogenesis
 

Preventive Measures

Although traditional recommendations to follow food and water precautions reduce the risk of contracting gastrointestinal illnesses like cholera, studies demonstrate that they are almost always hard for travelers to follow.1,29,30

Pathogenesis

Treatments

Antibiotics may shorten the duration of disease, but travelers with symptomatic cholera will still suffer the consequences of their illness24-26:

  • Profuse diarrhea

  • Need for rehydration (oral rehydration for mild to moderate cholera; IV rehydration for severe cholera)

  • Cost and inconvenience of a ruined trip

Pathogenesis
Pathogenesis

CDC Recommendations for Cholera

The CDC recommends the following precautions in areas where cholera is occurring or has occurred1:

Cholera

Drink and use safe water

Drink and use only bottled, boiled, or chemically treated water. Avoid tap water, fountain drinks, and ice cubes.

Cholera

Wash your hands

often with soap and clean water or hand sanitizer that is at least 60% alcohol.

Cholera

Cook food well

Eat foods that are packaged or freshly cooked and served hot.

Cholera

Dispose of feces

in a sanitary manner to avoid contamination of water and food sources.

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Cholera Vaccine Recommendation

Cholera

The CDC recommends vaccination against cholera for adult travelers (18 through 64 years of age) from the United States to areas of active cholera transmission, which is defined as a province, state, or other administrative subdivision within a country with endemic or epidemic cholera caused by toxigenic V. cholerae O1. This includes areas with cholera activity within the last year that are prone to recurrence of cholera epidemics; however, it does not include areas where there are only rare imported or sporadic cases.

For more information about CDC's cholera vaccine recommendation, click here.

References:
  1. Cholera—Vibrio cholerae infection: general information. Centers for Disease Control and Prevention website. http://www.cdc.gov/cholera/general/. Accessed January 26, 2016.
  2. Harris JB, LaRocque RC, Qadri F, Ryan ET, Calderwood SB. Cholera. Lancet. 2012;379(9835):2466-2476. doi:10.1016/S0140-6736(12)60436-X.
  3. Frequently asked questions. Stop Cholera website. https://www.stopcholera.org/content/frequently-asked-questions. Accessed 3/30/2016.
  4. Loharikar A, Newton A, Stroika S, et al. Cholera in the United States, 2001-2011: a reflection of patterns of global epidemiology and travel. Epidemiol Infect. 2015;143(4):695-703. doi:10.1017/S0950268814001186.
  5. World Health Organization. Global epidemics and impact of cholera. 2016. http://www.who.int/topics/cholera/impact/en/. Accessed January 26, 2016.
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  8. Youngdahl K. American presidents and infectious diseases. 2013; http://www.historyofvaccines.org/content/blog/american-presidents-and-infectious-diseases. Accessed January 27, 2016.
  9. Centers for Disease Control and Prevention. 150th anniversary of John Snow and the pump handle. MMWR Morb Mortal Wkly Rep. 2004;53(34):783.
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  12. UN News Centre. Haiti: senior UN official says cholera outbreak needs "urgent attention." 2015. http://www.un.org/apps/news/story.asp?NewsID=50867#.Vqe8u5orJpg. Accessed January 26, 2016.
  13. Frerichs R, Keim P, Barrais R, Piarroux R. Nepalese origin of cholera epidemic in Haiti. Clin Microbiol Infect. 2012;18(6):E158-E163. doi:10.1111/j.1469-0691.2012.03841.x.
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  15. Cholera in Tanzania. 2015. Centers for Disease Control and Prevention website. http://wwwnc.cdc.gov/travel/notices/watch/cholera-tanzania. Accessed January 29, 2016.
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  17. National Travel and Tourism Office. 2014 United States resident travel abroad. 2014; http://travel.trade.gov/outreachpages/download_data_table/2014_US_Travel_Abroad.pdf. Accessed June 14, 2014.
  18. World Health Organization. Cholera, 2014. Wkly Epidemiol Rec. 2015;90(40):517-528. http://www.who.int/wer/2015/wer9040/en/
  19. Slesak G, Fleck R, Jacob D, Grunow R, Schafer J. Imported cholera with acute renal failure after a short business-trip to the Philippines, Germany, October 2015. Euro Surveill. 2016;21(1):pii=30099. doi:10.2807/1560-7917.ES.2016.21.1.30099.
  20. Public Health Agency of Canada. Cholera in Cuba, Dominican Republic and Haiti. 2016; http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=111. Accessed June 17, 2017.
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