1

Cholera
30 March 2022

‫العربية‬

中文

Français

Русский

Español

Key facts
 Most of those infected will have no or mild symptoms and can be successfully
treated with oral rehydration solution.
 A global strategy on cholera control, Ending Cholera: a global roadmap to 2030,
with a target to reduce cholera deaths by 90% was launched in 2017.
 Researchers have estimated that each year there are 1.3 to 4.0 million cases of
cholera, and 21 000 to 143 000 deaths worldwide due to cholera (1)
 Cholera is an acute diarrhoeal disease that can kill within hours if left untreated.
 Provision of safe water and sanitation is critical to prevent and control the
transmission of cholera and other waterborne diseases.
 Severe cases will need rapid treatment with intravenous fluids and antibiotics.
 Oral cholera vaccines should be used in conjunction with improvements in water
and sanitation to control cholera outbreaks and for prevention in areas known to
be high risk for cholera.

Cholera is an acute diarrhoeal infection caused by ingestion of food or water

contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to
public health and an indicator of inequity and lack of social development.

Symptoms
Cholera is an extremely virulent disease that can cause severe acute watery
diarrhoea. It takes between 12 hours and 5 days for a person to show symptoms after
ingesting contaminated food or water (2). Cholera affects both children and adults and
can kill within hours if untreated.
 2

Most people infected with V. cholerae do not develop any symptoms, although
the bacteria are present in their faeces for 1-10 days after infection and are shed back
into the environment, potentially infecting other people.

Among people who develop symptoms, the majority have mild or moderate
symptoms, while a minority develop acute watery diarrhoea with severe dehydration.
This can lead to death if left untreated.

History
During the 19th century, cholera spread across the world from its original
reservoir in the Ganges delta in India. Six subsequent pandemics killed millions of
people across all continents. The current (seventh) pandemic started in South Asia in
1961, reached Africa in 1971 and the Americas in 1991. Cholera is now endemic in
many countries.

Vibrio cholerae strains
There are many serogroups of V. cholerae, but only two – O1 and O139 – cause
outbreaks. V. cholerae O1 has caused all recent outbreaks. V. cholerae O139 – first
identified in Bangladesh in 1992 – caused outbreaks in the past, but recently has only
been identified in sporadic cases. It has never been identified outside Asia. There is no
difference in the illness caused by the two serogroups.

Epidemiology, risk factors, and disease

burden
Cholera can be endemic or epidemic. A cholera-endemic area is an area where
confirmed cholera cases were detected during the last 3 years with evidence of local
transmission (meaning the cases are not imported from elsewhere). A cholera
outbreak/epidemic can occur in both endemic countries and in countries where cholera
does not regularly occur.

In cholera endemic countries an outbreak can be seasonal or sporadic and

represents a greater than expected number of cases. In a country where cholera does
not regularly occur, an outbreak is defined by the occurrence of at least 1 confirmed
 3

case of cholera with evidence of local transmission in an area where there is not usually
cholera.

Cholera transmission is closely linked to inadequate access to clean water and

sanitation facilities. Typical at-risk areas include peri-urban slums, and camps for
internally displaced persons or refugees, where minimum requirements of clean water
and sanitation are not been met.

The consequences of a humanitarian crisis – such as disruption of water and

sanitation systems, or the displacement of populations to inadequate and overcrowded
camps – can increase the risk of cholera transmission, should the bacteria be present or
introduced. Uninfected dead bodies have never been reported as the source of
epidemics.

The number of cholera cases reported to WHO has continued to be high over the
last few years. During 2020 323 369 cases, 857 deaths were notified from 24
countries 3. The discrepancy between these figures and the estimated burden of the
disease is due many cases not being recorded due to limitations in surveillance systems
and fear of impact on trade and tourism.

Prevention and control

A multifaceted approach is key to control cholera, and to reduce deaths. A
combination of surveillance, water, sanitation and hygiene, social mobilisation,
treatment, and oral cholera vaccines are used.

Surveillance
Cholera surveillance should be part of an integrated disease surveillance system
that includes feedback at the local level and information-sharing at the global level.

Cholera cases are detected based on clinical suspicion in patients who present
with severe acute watery diarrhoea. The suspicion is then confirmed by identifying V.
cholerae in stool samples from affected patients. Detection can be facilitated using rapid
diagnostic tests (RDTs), where one or more positive samples triggers a cholera alert. 
The samples are sent to a laboratory for confirmation by culture or PCR. Local capacity
to detect (diagnose) and monitor (collect, compile, and analyse data) cholera
 4

occurrence, is central to an effective surveillance system and to planning control

measures.

Countries affected by cholera are encouraged to strengthen disease surveillance

and national preparedness to rapidly detect and respond to outbreaks. Under the
International Health Regulations, notification of all cases of cholera is no longer
mandatory. However, public health events involving cholera must always be assessed
against the criteria provided in the regulations to determine whether there is a need for
official notification.

Water and sanitation interventions

The long-term solution for cholera control lies in economic development and
universal access to safe drinking water and adequate sanitation. Actions targeting
environmental conditions include the implementation of adapted long-term sustainable
WASH solutions to ensure use of safe water, basic sanitation and good hygiene
practices in cholera hotspots.  In addition to cholera, such interventions prevent a wide
range of other water-borne illnesses, as well as contributing to achieving goals related
to poverty, malnutrition, and education.  The WASH solutions for cholera are aligned
with those of the Sustainable Development Goals (SDG 6).

More information on  IHR Annex 2 

Treatment
Cholera is an easily treatable disease. The majority of people can be treated
successfully through prompt administration of oral rehydration solution (ORS). The
WHO/UNICEF ORS standard sachet is dissolved in 1 litre (L) of clean water. Adult
patients may require up to 6 L of ORS to treat moderate dehydration on the first day.

Severely dehydrated patients are at risk of shock and require the rapid
administration of intravenous fluids. These patients are also given appropriate
antibiotics to diminish the duration of diarrhoea, reduce the volume of rehydration fluids
needed, and shorten the amount and duration of V. cholerae excretion in their stool.

Mass administration of antibiotics is not recommended, as it has no proven effect

on the spread of cholera may contribute to antimicrobial resistance.
 5

Rapid access to treatment is essential during a cholera outbreak. Oral

rehydration should be available in communities, in addition to larger treatment centres
that can provide intravenous fluids and 24 hour care. With early and proper treatment,
the case fatality rate should remain below 1%.

Zinc is an important adjunctive therapy for children under 5, which also reduces
the duration of diarrhoea and may prevent future episodes of other causes of acute
watery diarrhoea.

Breastfeeding should also be promoted.

Community Engagement
Community Engagement means that people and communities are part of the
process of developing and implementing programmes.  Local culture practices and
beliefs are central to promoting actions such as the adoption of protective hygiene
measures such as handwashing with soap, safe preparation and storage of food and
safe disposal of the faeces of children.funeral practices for individuals who die from
cholera  to prevent infection among attendees.

Community engagement continues throughout outbreak response with increased

communication regarding potential risks,  symptoms of cholera, precautions to take to
avoid cholera, when and where to report cases and to seek immediate treatment when
symptoms appear.  The communities should be part of developing programmes to
address needs including where and when to seek treatment.

Oral cholera vaccines

Currently there are three WHO pre-qualified oral cholera vaccines (OCV):
Dukoral®, Shanchol™, and Euvichol-Plus®. All three vaccines require two doses for full
protection.

Dukoral® is administered with a buffer solution that, for adults, requires 150 ml of
clean water. Dukoral can be given to all individuals over the age of 2 years. There must
be a minimum of 7 days, and no more than 6 weeks, delay between each dose.
Children aged 2 -5 require a third dose. Dukoral® is mainly used for travellers. Two
doses of Dukoral® provide protection against cholera for 2 years.
 6

Shanchol™ and Euvichol-Plus® have the same vaccine formula, produced by

two different manufacturers. They do not require a buffer solution for administration.
They are given to all individuals over the age of one year. There must be a minimum of
two weeks delay between each dose of these two vaccines. Two doses of Shanchol™
and Euvichol-Plus® provide protection against cholera at least for three years, while
one dose provides short term protection.

Shanchol™ is prequalified to be used in a Controlled Temperature Chain, an

innovative approach to vaccine management allowing vaccines to be kept at
temperatures outside of the traditional cold chain of +2°C to +8°C for a limited period of
time under monitored and controlled conditions.

More information on Control Temperature Chain can be found here

Shanchol™ and Euvichol-Plus® are the vaccines currently available for mass
vaccination campaigns through the Global OCV Stockpile. The stockpile is supported by
Gavi, the Vaccine Alliance.

Based on the available evidence, the August 2017 WHO Position Paper on
Vaccines against Cholera states that:

 OCV should be used in areas with endemic cholera, in humanitarian crises with high risk
of cholera, and during cholera outbreaks; always in conjunction with other cholera
prevention and control strategies;
 vaccination should not disrupt the provision of other high priority health interventions to
control or prevent cholera outbreaks.

More than 100 million doses of OCV have been used in mass vaccination
campaigns. The campaigns have been implemented in areas experiencing an outbreak,
in areas at heightened vulnerability during humanitarian crises, and among populations
living in highly endemic areas, known as “hotspots”.

 More information on cholera vaccines

 The 2017 WHO OCV position paper

WHO response
In 2014 the Global Task Force on Cholera Control (GTFCC), with its Secretariat
based at WHO, was revitalised. The GTFCC is a network of more than 50 partners
 7

active in cholera control globally, including academic institutions, non-governmental

organisations and United Nations agencies.

Through the GTFCC and with support from donors, WHO works to:

 promote the design and implementation of global strategies to contribute to capacity

development for cholera prevention and control globally;
 provide a forum for technical exchange, coordination, and cooperation on cholera-
related activities to strengthen country capacity to prevent and control cholera;
 support countries for the implementation of effective cholera control strategies and
monitoring of progress;
 disseminate technical guidelines and operational manuals;
 support the development of a research agenda with emphasis on evaluating innovative
approaches to cholera prevention and control in affected countries; and
 increase the visibility of cholera as an important global public health problem through the
dissemination of information about cholera prevention and control, and conducting
advocacy and resource mobilization activities to support cholera prevention and control
at national, regional, and global levels.

To strengthen GTFCC support to countries, in 2020 a Country Support Platform

( CSP) was established. The CSP, hosted by the International Federation of Red Cross
and Red Crescent Societies (IFRC) provides multisectoral operational support as well
as advocacy, coordination, and policy guidance necessary for countries to develop,
fund, implement and monitor their NCPs effectively in alignment with the Global
Roadmap.

More about the Global Task Force on Cholera Control (GTFCC) and the Country
support Platform (CSP)

Ending Cholera: a Roadmap to 2030

In October 2017, GTFCC partners launched a strategy for cholera control Ending
Cholera: A global roadmap to 2030. The country led strategy aims to reduce cholera
deaths by 90% and to eliminate cholera in as many as 20 countries by 2030.

The Global Roadmap focuses on three strategic axes:

1. Early detection and quick response to contain outbreaks: the strategy focuses on
containing outbreaks—wherever they may occur— through early detection and rapid
multisectoral response including community, engagement, strengthening surveillance
and laboratory capacity, health systems and supply readiness, and supporting rapid
response teams.
2. A targeted multi-sectoral approach to prevent cholera recurrence: the strategy calls on
countries and partners to focus on cholera “hotspots”, the relatively small areas most
 8

heavily affected by cholera. Cholera transmission can be stopped in these areas through
measures including improved WASH and through use of OCV.
3. An effective mechanism of coordination for technical support, advocacy, resource
mobilisation, and partnership at local and global levels: The GTFCC provides a strong
framework to support countries to intensify efforts to control cholera, building upon
country-led cross-sectoral cholera control programs and supporting them with human,
technical, and financial resources.

A resolution promoting control of cholera and endorsing "Ending Cholera: A

global roadmap to 2030" was passed in May 2018 at the 71st World Health Assembly.

More about the strategy

Cholera Kits

To ensure efficient and effective deployment of necessary materials for the

investigation and confirmation of cholera outbreaks, as well as the treatment of cholera
patients, WHO has developed a set of cholera kits.

In 2016, after consultation with implementing partners, WHO revised the cholera
kits to better meet field needs. There are 6 kits:

 1 for investigation
 1 with supplies for laboratory confirmation
 3 for treatment at each of the community, peripheral and central levels
 1 support kit with logistical materials including solar lamps, fencing, water bladders and
taps.

Each treatment kit provides enough material to treat 100 patients. The revised
cholera kits are designed to help prepare for a potential cholera outbreak and to support
the first month of the initial response.

More about cholera kits

References
(1) Updated global burden of cholera in endemic countries.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455997/
 9

Ali M, Nelson AR, Lopez AL, Sack D. (2015). PLoS Negl Trop Dis 9(6):
e0003832. doi:10.1371/journal.pntd.0003832.

(2) The incubation period of cholera: a systematic review.

https://www.ncbi.nlm.nih.gov/pubmed/23201968
Azman AS, Rudolph KE, Cummings DA, Lessler J. J Infect. 2013;66(5):432-8. doi:
10.1016/j.jinf.2012.11.013. PubMed PMID: 23201968; PubMed Central PMCID:
PMC3677557.

(3) Cholera Annual Report 2020 Weekly Epidemiological Record 37 September

2021, Vol 96, (pp 445-460).

(4) Cholera vaccines: WHO position paper – August 2017

http://apps.who.int/iris/bitstream/10665/258764/1/WER9234-477-498.pdf

Weekly Epidemiological Record 25 August 2017, No 34, 2017, 92, 477–500.