Cholera is a serious infection of the intestine that is caused by the gram-negative bacteria Vibrio cholerae. This infection causes severe diarrhea, which can be fatal without treatment.
People are infected when they consume contaminated food, often shellfish, or water.
Cholera is rare except in areas where sanitation is inadequate.
People have watery diarrhea and vomit, usually with no fever.
Identifying the bacteria in a stool sample confirms the diagnosis.
Replacing lost fluids and giving antibiotics treat the infection effectively.
(See also Overview of Bacteria.)
Several species of Vibrio bacteria cause diarrhea (see table Microorganisms That Cause Gastroenteritis). The most serious illness, cholera, is caused only by Vibrio cholerae.
Vibrio cholerae infection is acquired by consuming water, shellfish, or other foods contaminated by the stool of infected people. Once infected, people excrete the bacteria in stool. Thus, the infection can spread rapidly, particularly in areas where human waste is untreated.
Once common throughout the world, cholera is now most common in parts of Asia, the Middle East, Africa, and South and Central America. Small outbreaks have occurred in Europe, Japan, and Australia. In the United States, cholera can occur along the coast of the Gulf of Mexico.
Large outbreaks of cholera continue to occur wherever there is poverty and people lack access to clean drinking water and sanitary disposal of human waste. A severe cholera epidemic occurred in Haiti after the earthquake in 2010 and lasted until 2017. During this outbreak, over 820,000 people became ill, and nearly 10,000 died. An outbreak in Yemen started in 2016 and has not yet ended. This outbreak has had even greater devastating effects. Over 2.5 million people in Yemen have become ill, and almost 4,000 have died. It is thought to be the largest, fastest-spreading cholera outbreak in modern history, and, at its peak in 2019, accounted for over 90% of cholera cases in the world. Haiti also had a new outbreak that started at the end of 2022 after the country had been declared cholera-free for 3 years. It has not yet ended.
Cholera outbreaks have increased globally since 2021, and reported cases doubled from 2021 to 2022. In 2022, 7 countries in Africa and Asia reported outbreaks of more than 10,000 cases each.
In endemic areas (areas where there is an ongoing, relatively constant rate of infection), outbreaks usually occur when war or civil unrest disrupts public sanitation services. Infection is most common during warm months and especially among young or undernourished children. In newly affected areas, outbreaks may occur during any season and affect all ages equally.
For infection to develop, many bacteria must be consumed. Then, there may be too many for stomach acid to kill, and some bacteria can reach the small intestine, where they grow and produce a toxin. The toxin causes the small intestine to secrete enormous amounts of salt and water. The body loses this fluid as watery diarrhea. It is the loss of water and salt that causes death. The bacteria remain in the small intestine and do not invade other tissues.
Because stomach acid kills the bacteria, people who produce less stomach acid are more likely to get cholera. Such people include
Young children
Older adults
People who have type O blood are also at greater risk of infection.
People living in endemic areas gradually acquire some immunity.
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Symptoms of Cholera
Most infected people have no symptoms.
When cholera symptoms occur, they begin 1 to 3 days after exposure, usually with sudden, painless, watery diarrhea and vomiting. Usually, people have no fever.
Diarrhea and vomiting may be mild to severe. In severe infections in adults, more than 1 quart (1 liter) of water and salts is lost per hour. The stool is profuse and watery and is described as rice-water stool. Within hours, dehydration can become severe, causing intense thirst, muscle cramps, and weakness. Very little urine is produced. The eyes may become sunken, and the skin on the fingers may become very wrinkled. If dehydration is not treated, loss of water and salts can lead to kidney failure, shock, coma, and death.
In people who receive treatment, cholera symptoms usually subside in 3 to 6 days.
Most people are free of the bacteria in 2 weeks. The bacteria remain in a few people indefinitely without causing symptoms. Such people are called carriers.
Diagnosis of Cholera
Culture of a sample of stool
Doctors take a sample of stool or use a swab to obtain a sample from the rectum. It is sent to a laboratory where cholera bacteria, if present, can be grown (cultured). Identifying Vibrio cholerae in the sample confirms the diagnosis. Doctors may use the polymerase chain reaction (PCR) technique to increase the amount of the bacteria's genetic material (DNA) so that the bacteria can be detected more quickly.
Blood and urine tests to evaluate dehydration and kidney function are done.
Treatment of Cholera
Fluids that contain salt
An antibiotic
Replacement of lost body water and salts
Rapid replacement of lost body water and salts is lifesaving. Most people can be treated effectively with a solution given by mouth. These solutions are designed to replace the fluids the body has lost.
For severely dehydrated people who cannot drink, a salt solution is given intravenously.
In epidemics, if the intravenous solution is not available, people are given a salt solution by mouth or, if needed, through a tube inserted through the nose into the stomach. After enough fluids are replaced to relieve symptoms, people should drink at least enough of the salt solution to replace the fluids they have lost through diarrhea and vomiting.
People are also encouraged to drink as much water as they want. Solid foods can be eaten after vomiting stops and appetite returns.
Antibiotics
An antibiotic is usually given to reduce the severity of diarrhea and make it stop sooner. Also, people who take an antibiotic are slightly less likely to spread the infection during an outbreak.
For children in low-resource areas, zinc supplements can help reduce the severity and duration of symptoms.
Prevention of Cholera
The following are essential to cholera prevention:
Purification of water supplies
Appropriate disposal of human waste
In areas where cholera occurs, other precautions include
Using boiled or chlorinated water
Avoiding uncooked vegetables and undercooked shellfish
Shellfish tend to carry other forms of Vibrio as well.
Vaccines
In the United States, a cholera vaccine (Vaxchora) is available for people aged 2 to 64 years if they are traveling to areas where cholera occurs. It is taken by mouth in a single dose. However, whether this vaccine is effective for more than 3 to 6 months is unknown.
Three other vaccines for cholera are available outside the United States (Dukoral, ShanChol, and Euvichol). These vaccines provide 60 to 85% protection for 2 to 3 years. These vaccines are taken by mouth in 2 doses. Booster doses are recommended after 2 years for people who continue to be at risk of getting cholera.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
Centers for Disease Control and Prevention (CDC): Cholera: A resource providing information about cholera, including outbreaks and risk factors
