Cholera is an intestinal infection caused by the bacterium Vibrio cholerae (V. cholerae) that has the potential to kill within hours.1,2
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
Cholera is estimated to be endemic in 69 countries, primarily
in Africa, Asia, and the Caribbean.16
People's Republic of China
Recent cases also demonstrate travelers can get cholera
in countries that are not considered endemic, including popular tourist destinations like
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 typically appear in 2 to 3 days, but disease onset may vary froma 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
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
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
In the US, the CDC estimates the true number of cholera cases to be asmuch 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:
After ingestion of a large enough dose of bacteria that are able to survivegastric 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
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
Antibiotics may shorten the duration of disease, but travelers with symptomatic cholera will still suffer the consequences of their illness24-26:
Need for rehydration (oral rehydration for
mild to moderate cholera; IV rehydration
for severe cholera)
Cost and inconvenience of a ruined trip
The CDC recommends the following precautions in areas
where cholera is occurring or has occurred1:
Drink and use only bottled, boiled, or chemically treated water. Avoid tap water, fountain drinks, and ice cubes.
often with soap and clean water or hand sanitizer that is at least 60% alcohol.
Eat foods that are packaged orfreshly cooked and served hot.
in a sanitary manner to avoid contamination of water and food sources.
The ACIP voted on June 22, 2016, to recommend use of VaxchoraTM (Cholera Vaccine, Live, Oral) as a prevention for cholera for travelers to areas of active cholera transmission. More information to follow when the detailed recommendation is published in MMWR.31