Cholera has been very rare in industrialized nations for the last 100 years; however, the disease is still common today in other parts of the world, including the Indian subcontinent and sub-Saharan Africa. Although cholera can be life-threatening, it is easily prevented and treated. In the United States, because of advanced water and sanitation systems, cholera is not a major threat; however, everyone, especially travelers, should be aware of how the disease is transmitted and what can be done to prevent it. CDC responds to cholera outbreaks across the world using its Global Water, Sanitation, & Hygiene (WASH) expertise. What is Cholera? Cholera is an acute intestinal infection causing profuse watery diarrhea, vomiting, circulatory collapse and shock. Many infections are milder diarrhea or are asymptomatic. Brackish and marine waters are a natural environment for the etiologic agents of cholera, Vibrio cholerae 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. In 2009, 45 countries reported 221,226 cholera cases and 4,946 cholera deaths (case-fatality rate 2.24%) to the World Health Organization (WHO). Resource-poor areas continue to report the vast majority of cases; 99% of cases were reported from Africa, continuing a trend. The disease is caused by toxigenic Vibrio cholerae O-group 1 or O-group 139. Only toxigenic strains of serogroups O1 and O139 have caused widespread epidemics and are reportable to the World Health Organization (WHO) as "cholera". Click here for more information on illness caused by non-O1 and non-O139 V. cholerae serogroup infections. V. cholerae O1 has two biotypes, Classical and El Tor, and each biotype has two distinct serotypes, Inaba and Ogawa. 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. Click here for more information on illness caused by non-O1 and non-O139 V. cholerae serogroup infections. Cholera is a major cause of epidemic diarrhea throughout the developing world. There has been an ongoing global pandemic in Asia, Africa and Latin America for the last four decades. In the United States, incidence is very low (0-5 cases per year) due to ingestion of contaminated food. If left untreated, 25-50% of typical cholera cases are fatal. Where is Cholera Found? Cholera is a very serious waterborne disease. The Ghost Map: The Story of London's Most Terrifying Epidemic--and How It Changed Science, Cities, and the Modern World Love in the Time of Cholera (Vintage International) 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 United States 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. 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 of transmission mean that successful prevention may require different specific 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. What are the Symptoms of Cholera? Approximately one in 20 (5-10%) of 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 Persons with severe cholera can develop acute renal failure, severe electrolyte imbalances and coma. If untreated, severe dehydration can rapidly lead to shock and death within hours.   Buy Zithromax for treating bacterial infections, skin infections, sexually transmitted infectious diseases, urethritis. medicstar.com Buy Propecia Propecia is used to treat hair loss. Propecia is not addictive. www-medic.com Buy Brand Viagra Viagra is applied for the treatment of erectile dysfunction in men. Buy Viagra Super Force Buy Amoxicillin one of the best antibiotic. Amoxicillin used to treat infections caused by certain bacteria. medicstar.com Profuse diarrhea produced by cholera patients contains large amounts of infectious Vibrio cholerae bacteria that can infect others if ingested, and when these bacteria contaminate water or food will lead to additional cases. Persons caring for cholera patients can avoid acquiring illness by washing their hands after touching anything that might be contaminated and properly disposing of contaminated items. Infected persons, when treated rapidly, can recover quickly, and there are typically no long term consequences. Persons with cholera do not become carriers of the disease after they recover, but can be reinfected if exposed again. How Long After Infection Do the Symptoms Appear? It can take anywhere from a few hours to 5 days for symptoms to appear after infection. Symptoms typically appear in 2-3 days. Who is Most Likely to Get Cholera? Individuals living in places with inadequate water treatment, poor sanitation, and inadequate hygiene are at a greater risk for cholera. What Should I Do If I Think I Have Cholera? If you think you may 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 now; it can save your life Go immediately to the nearest health facility. Continue to drink ORS at home and while you travel to get treatment Continue to breastfeed your baby if they have watery diarrhea, even when traveling to get treatment How is Cholera Diagnosed? Cholera is confirmed through culture of a stool specimen or rectal swab. 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. More detailed information is available for laboratory diagnosis of Vibrio cholerae in resource poor areas and for Reference Laboratories. Cholera is a U.S. nationally reportable disease. All isolates should be sent to CDC via state health department laboratories for cholera toxin-testing and subtyping. Vibrio cholerae growing on thiosulphate citrate bile salt sucrose(TCBS) agar plates 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, a prepackaged mixture of sugar and salts to be mixed with 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 rehydration, fewer than 1% of cholera patients die. WHO Fluid Replacement or Treatment Recommendations No dehydration Oral rehydration salts Children<2 years: 50–100 ml, up to 500 mL / day Children 2–9 years: 100–200 ml, up to 1000 mL / day Patients >9 years: As much as wanted, to 2000 mL / day Some dehydration Oral rehydration salts (amount in first 4 hours) Infants<4 mos (<5 kg): 200–400 mL Infants 4–11 mos (5–7.9 kg): 400–600 mL Children 1–2 yrs (8–10.9 kg): 600–800 mL Children 2–4 yrs (11–15.9 kg): 800–1200 mL Children 5–14 yrs (16–29.9 kg): 1200–2200 mL Patients >14 yrs (30 kg or more): 2200–4000 mL Severe dehydration IV drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined above Age < 12 months: 30 mL/kg within 1 hour*, then 70 ml/kg over 5 hours Age > 1 year: 30 mL/kg within 30 min*, then 70 ml/kg over two-and-a-half hours *Repeat once if radial pulse is still very weak or not detectable Reassess the patient every 1-2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200ml/kg or more may be needed during the first 24 hours of treatment After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink Antibiotics reduce fluid requirements and duration of illness. Antibiotics are indicated for severe cases, which can be treated with tetracycline, doxycycline, furazolidone, erythromycin, or ciprofloxacin. When possible, antimicrobial susceptibility testing should inform treatment choices. Persons who develop severe diarrhea and vomiting in countries where cholera occurs should seek medical attention promptly. While simple rehydration treatment saves lives, 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 in warm coastal waters make eradication very unlikely. 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? The risk for cholera is very low for people visiting areas with epidemic cholera. When simple precautions are observed, contracting the disease is unlikely. All people (visitors or residents) in areas where cholera is occurring or has occurred should observe the following recommendations: Drink and use safe water* Bottled water with unbroken seals and canned/bottled carbonated beverages are safe to drink and use Use safe water to brush your teeth, wash and prepare food, and to make ice Clean food preparation areas and kitchenware with soap and safe water and let dry completely before reuse *Piped water sources, drinks sold in cups or bags, or ice may not be safe and should be boiled or treated with chlorine. To be sure water is safe to drink and use: Boil it or treat it with a chlorine product or household bleach If boiling, bring your water to a complete boil for at least 1 minute To treat your water with chlorine, 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. Add 8 drops of household bleach for every 1 gallon of water (or 2 drops of household bleach for every 1 liter of water) and wait 30 minutes before drinking Always store your treated water in a clean, covered container Wash your hands often with soap and safe water* Before you eat or prepare food Before feeding your children After using the latrine or toilet After cleaning your child’s bottom After taking care of someone ill with diarrhea * If no soap is available, scrub hands often with ash or sand and rinse with safe water. Use latrines or bury your feces (poop); do not defecate in any body of water Use latrines or other sanitation systems, like chemical toilets, to dispose of feces Wash hands with soap and safe water after defecating Clean latrines and surfaces contaminated with feces using a solution of 1 part household bleach to 9 parts water What if I don’t have a latrine or chemical toilet? Defecate at least 30 meters away from any body of water and then bury your feces Dispose of plastic bags containing feces in latrines, at collection points if available, or bury it in the ground. Do not put plastic bags in chemical toilets Dig new latrines or temporary pit toilets at least a half-meter deep and at least 30 meters away from any body of water Cook food well (especially seafood), keep it covered, eat it hot, and peel fruits and vegetables* Boil it, Cook it, Peel it, or Leave it 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 you have peeled yourself. 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 away from drinking water sources Is a Vaccine Available to Prevent Cholera? Currently, there are two oral cholera vaccines available, Dukoral (manufactured by SBL Vaccines) which is World Health Organization (WHO) prequalified and licensed in over 60 countries, and ShanChol (manufactured by Shantha Biotec in India), which is licensed in India and is pending WHO prequalification. Because the vaccine is a two dose vaccine, multiple weeks can elapse before persons receiving the vaccine are protected. Therefore, vaccination should not replace standard prevention and control measures. In addition, CDC does not recommend cholera vaccines for most travelers, nor is the vaccine available in the United States. This is because the available vaccines offer incomplete protection for a relatively short period of time. Further information about Dukoral can be obtained from the manufacturers: Dukoral® SBL Vaccin AB, SE-105 21 Stockholm, Sweden telephone +46-8-7351000 website What is the Risk For Cholera in the United States? In the United States, cholera was prevalent in the 1800s but water-related spread has been eliminated by modern water and sewage treatment systems. However, U.S. travelers to areas with epidemic cholera (for example, parts of Africa, Asia, or Latin America) may be exposed to the cholera bacterium. In addition, travelers may bring contaminated seafood back to the United States; foodborne outbreaks of cholera have been caused by contaminated seafood brought into the United States by travelers. In the U.S., there has been a modest increase in imported cases since 1991 related to travel and ongoing epidemics. The Cholera Years: The United States in 1832, 1849, and 1866 Where Can a Traveler Get Information About Cholera? The global picture of cholera changes periodically, so travelers should seek updated information on countries of interest. CDC has a Travelers' Health Website that contains information on cholera and other diseases of concern to travelers. Cholera Confirmed in Haiti, October 21, 2010 An outbreak of cholera was confirmed in Haiti on October 21, 2010. Cholera had not been documented in Haiti for decades so cholera outbreaks were considered unlikely in Haiti immediately following the earthquake in January, 2010. For a cholera outbreak to occur, two conditions have to be met: (1) there must be significant breaches in the water, sanitation, and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio cholerae organisms; and (2) cholera must be present in the population. While it is unclear how cholera was re-introduced to Haiti, both of these conditions now exist. Cholera infection is most often asymptomatic or causes a mild gastroenteritis. However, about 5% of infected persons develop severe, dehydrating, acute watery diarrhea. The first line of treatment for cholera is rehydration. Administration of oral rehydration salts and, when necessary, intravenous fluids and electrolytes in a timely manner with adequate volumes will reduce case-fatality rates to less than 1%. Severe cases of cholera should be treated with antimicrobial agents to which the circulating strain is susceptible. Antimicrobial treatment is not recommended for mild cases of cholera and should never be used as “chemoprophylaxis” to prevent cholera on a mass scale. As with other causes of acute watery diarrhea, the prevention and control of cholera require surveillance, heightened measures to ensure the safety of drinking water and food, and appropriate facilities and practices for disposal of feces and for handwashing. Although using vaccines to control an outbreak of cholera is complex, oral cholera vaccines are being considered for use among high-risk populations in Haiti. CDC is working closely with other U.S. government agencies and international partners in support of the Haitian government’s response to the cholera outbreak in that country. CDC is collaborating with the U.S. Agency for International Development, the Pan American Health Organization, the United Nations Children’s Fund, and a host of other organizations to assist the Haiti Ministry of Public Health and Population (MSPP) in a concerted effort to control the outbreak. What is the U.S. Government Doing to Combat Cholera? U.S. and international public health authorities are working to enhance surveillance for cholera, investigate cholera outbreaks, and design and implement preventive measures across the globe. The Centers for Disease Control and Prevention (CDC) investigates epidemic cholera wherever it occurs at the invitation of the affected country and trains laboratory workers in proper techniques for identification of Vibrio cholerae. In addition, CDC provides information on diagnosis, treatment, and prevention of cholera to public health officials and educates the public about effective preventive measures. The U.S. Agency for International Development sponsors some of the international U.S. government activities and provides medical supplies, and water, sanitation and hygiene supplies to affected countries. The Food and Drug Administration tests imported and domestic shellfish for V. cholerae and monitors the safety of U.S. shellfish beds through the shellfish sanitation program. With cooperation at the state and local, national, and international levels, assistance will be provided to countries where cholera is present. The risk to U.S. residents remains small.