Cholera

Fact sheet N107

August 2011

Key facts
O holera is an acute diarrhoeal disease that can kill within hours iI leIt untreated.
O %here are an estimated 35 million cholera cases and 100 000120 000 deaths due to cholera every year.
O &5 to 80 oI cases can be successIully treated with oral rehydration salts.
O IIective control measures rely on 5revention, 5re5aredness and res5onse.
O !rovision oI saIe water and sanitation is critical in reducing the im5act oI cholera and other waterborne diseases.
O ral cholera vaccines are considered an additional means to control cholera, but should not re5lace conventional control measures.

holera is an acute diarrhoeal inIection caused by ingestion oI Iood or water contaminated with the bacterium Jibrio cholerae. very year, there are an estimated 35 million cholera cases and 100 000120 000 deaths due to cholera. %he
short incubation 5eriod oI two hours to Iive days, enhances the 5otentially ex5losive 5attern oI outbreaks.
$ymptoms
holera is an extremely virulent disease. It aIIects both children and adults and can kill within hours.
About 75 oI 5eo5le inIected with J. cholerae do not develo5 any sym5toms, although the bacteria are 5resent in their Iaeces Ior 714 days aIter inIection and are shed back into the environment, 5otentially inIecting other 5eo5le.
Among 5eo5le who develo5 sym5toms, 80 have mild or moderate sym5toms, while around 20 develo5 acute watery diarrhoea with severe dehydration. %his can lead to death iI untreated.
!eo5le with low immunity such as malnourished children or 5eo5le living with HIV are at a greater risk oI death iI inIected.
story
uring the 19th century, cholera s5read across the world Irom its original reservoir in the Ganges delta in India. Six subsequent 5andemics killed millions oI 5eo5le across all continents. %he current (seventh) 5andemic started in South Asia
in 1961, and reached AIrica in 1971 and the Americas in 1991. holera is now endemic in many countries.
Jibrio cholerae stra3s
%wo serogrou5s oI J. cholerae 1 and 139 cause outbreaks. J. cholerae 1 causes the majority oI outbreaks, while 139 Iirst identiIied in Bangladesh in 1992 is conIined to South-ast Asia.
Non-1 and non-139 J. cholerae can cause mild diarrhoea but do not generate e5idemics.
Recently, new variant strains have been detected in several 5arts oI Asia and AIrica. bservations suggest that these strains cause more severe cholera with higher case Iatality rates. areIul e5idemiological monitoring oI circulating strains
is recommended.
%he main reservoirs oI J. cholerae are 5eo5le and aquatic sources such as brackish water and estuaries, oIten associated with algal blooms. Recent studies indicate that global warming creates a Iavourable environment Ior the bacteria.
#sk factors a3/ /sease bur/e3
holera transmission is closely linked to inadequate environmental management. %y5ical at-risk areas include 5eri-urban slums, where basic inIrastructure is not available, as well as cam5s Ior internally dis5laced 5eo5le or reIugees, where
minimum requirements oI clean water and sanitation are not met.
%he consequences oI a disaster such as disru5tion oI water and sanitation systems, or the dis5lacement oI 5o5ulations to inadequate and overcrowded cam5s can increase the risk oI cholera transmission should the bacteria be 5resent or
introduced. 5idemics have never arisen Irom dead bodies.
holera remains a global threat to 5ublic health and a key indicator oI lack oI social develo5ment. Recently, the re-emergence oI cholera has been noted in 5arallel with the ever-increasing size oI vulnerable 5o5ulations living in unsanitary
conditions.
%he number oI cholera cases re5orted to WH continues to rise. From 2004 to 2008, cases increased by 24 com5ared with the 5eriod Irom 2000 to 2004. For 2008 alone, a total oI 190 130 cases were notiIied Irom 56 countries, including
5143 deaths. Many more cases were unaccounted Ior due to limitations in surveillance systems and Iear oI trade and travel sanctions. %he true burden oI the disease is estimated to be 35 million cases and 100 000120 000 deaths annually.
Preve3to3 a3/ co3trol
A multidisci5linary a55roach based on 5revention, 5re5aredness and res5onse, along with an eIIicient surveillance system, is key Ior mitigating cholera outbreaks, controlling cholera in endemic areas and reducing deaths.
Treatme3t
holera is an easily treatable disease. &5 to 80 oI 5eo5le can be treated successIully through 5rom5t administration oI oral rehydration salts (WH&NIF RS standard sachet). Very severely dehydrated 5atients require administration
oI intravenous Iluids. Such 5atients also require a55ro5riate antibiotics to diminish the duration oI diarrhoea, reduce the volume oI rehydration Iluids needed, and shorten the duration oI J. cholerae excretion. Mass administration oI
antibiotics is not recommended, as it has no eIIect on the s5read oI cholera and contributes to increasing antimicrobial resistance.
In order to ensure timely access to treatment, cholera treatment centres (%s) should be set u5 among the aIIected 5o5ulations. With 5ro5er treatment, the case Iatality rate should remain below 1.
utbreak respo3se
nce an outbreak is detected, the usual intervention strategy is to reduce deaths by ensuring 5rom5t access to treatment, and to control the s5read oI the disease by 5roviding saIe water, 5ro5er sanitation and health education Ior im5roved
hygiene and saIe Iood handling 5ractices by the community. %he 5rovision oI saIe water and sanitation is a Iormidable challenge but remains the critical Iactor in reducing the im5act oI cholera.
ral cholera vacc3es
%here are two ty5es oI saIe and eIIective oral cholera vaccines currently available on the market. Both are whole-cell killed vaccines, one with a recombinant B-sub unit, the other without. Both have sustained 5rotection oI over 50 lasting
Ior two years in endemic settings.
ne vaccine (ukoral) is WH 5requaliIied and licensed in over 60 countries. ukoral has been shown to 5rovide short-term 5rotection oI 8590 against J. cholerae 1 among all age grou5s at 46 months Iollowing immunization.
%he other vaccine (Shanchol) is 5ending WH 5requaliIication and 5rovides longer-term 5rotection against J. cholerae 1 and 139 in children under Iive years oI age.
Both vaccines are administered in two doses given between seven days and six weeks a5art. %he vaccine with the B-subunit (ukoral) is given in 150 ml oI saIe water.
WH recommends that immunization with currently available cholera vaccines be used in conjunction with the usually recommended control measures in areas where cholera is endemic as well as in areas at risk oI outbreaks. Vaccines
5rovide a short term eIIect while longer term activities like im5roving water and sanitation are 5ut in 5lace.
When used, vaccination should target vulnerable 5o5ulations living in high risk areas and should not disru5t the 5rovision oI other interventions to control or 5revent cholera e5idemics. %he WH 3-ste5 decision making tool aims at
guiding health authorities in deciding whether to use cholera vaccines in com5lex emergency settings.
%he use oI the 5arenteral cholera vaccine has never been recommended by WH due to its low 5rotective eIIicacy and the high occurrence oI severe adverse reactions.
Travel a3/ tra/e
%oday, no country requires 5rooI oI cholera vaccination as a condition Ior entry. !ast ex5erience shows that quarantine measures and embargoes on the movement oI 5eo5le and goods are unnecessary. Isolated cases oI cholera related to
im5orted Iood have been associated with Iood in the 5ossession oI individual travellers. onsequently, im5ort restrictions on Iood 5roduced under good manuIacturing 5ractices, based on the sole Iact that cholera is e5idemic or endemic in a
country, are not justiIied.
ountries neighbouring cholera-aIIected areas are encouraged to strengthen disease surveillance and national 5re5aredness to ra5idly detect and res5ond to outbreaks should cholera s5read across borders. Further, inIormation should be
5rovided to travellers and the community on the 5otential risks and sym5toms oI cholera, together with 5recautions to avoid cholera, and when and where to re5ort cases.
W respo3se
%hrough the WH Global %ask Force on holera ontrol, WH works to:
O 5rovide technical advice and su55ort Ior cholera control and 5revention at country level
O train health 5roIessionals at national, regional and international levels in 5revention, 5re5aredness and res5onse oI diarrhoeal disease outbreaks
O disseminate inIormation and guidelines on cholera and other e5idemic-5rone enteric diseases to health 5roIessionals and the general 5ublic

$evere Acute Watery Darrhoea wth V. choleraepostve cases 3 Vet Nam
22 A!RIL 2008 - Between 5 March and 22 A5ril the Ministry oI Health oI Viet Nam re5orted 2490 cases oI severe acute watery diarrhoea including 377 that were 5ositive Ior Vibrio cholerae , the bacterium causing cholera. %he seroty5e
has been identiIied as 01 gawa. No deaths have been re5orted, a Iact that indicates that good case management is in 5lace.
&ntil now, 20 5rovinces and munici5alities oI Viet Nam have been aIIected. %he majority oI 5eo5le inIected by the disease are Hanoi residents. %he 5redominant route oI inIection a55ears to be consum5tion oI contaminated Iood. holera
bacteria have not been detected in drinking water in Hanoi or in other aIIected areas but have been Iound in some surIace waters. Additional e5idemiological, environmental and Iood trace-back investigations are under way.
%he Ministry oI Health has been increasing health education and launched a mass media cam5aign aimed at strengthening Iood saIety and 5ersonal hygiene knowledge and 5ractices. nvironmental disinIection is conducted in the homes oI
cholera 5atients and a 5rogram oI intensiIied hygiene ins5ection oI commercial Iood vendors is being carried out.
WH is su55orting the Ministry oI Health by 5roviding technical advice on as5ects oI the e5idemiological and laboratory investigations oI the outbreak. In addition, WH and other &N agencies are ex5loring other 5ossibilities oI
assistance.
In controlling the s5read oI cholera WH does not recommend any s5ecial restrictions to travel or trade to or Irom aIIected areas. Visitors coming to Viet Nam are encouraged to res5ect basic 5recautions when consuming water and Iood.