CHOLERA http://www.cdc.gov/cholera/index.

html 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.

General Information What is Cholera? Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. An estimated 3-5 million cases and over 100,000 deaths occur each year around the world. The infection is often mild or without symptoms, but can sometimes be severe. Approximately one in 20 (5%) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.

Where is Cholera Found? 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. What are the Symptoms of Cholera? Cholera infection is often mild or without symptoms, but can sometimes be severe. Approximately one in 20 (5%) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.

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.

How is Cholera Diagnosed? To test for cholera, doctors must take a stool sample or a rectal swab and send it to a laboratory to look for the cholera bacterium.

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.

Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as receiving rehydration. Persons who develop severe diarrhea and vomiting in countries where cholera occurs should seek medical attention promptly.

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 only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken. To disinfect your own water: boil for 1 minute or filter the water and add 2 drops of household bleach or an iodine tablet per liter of water. Avoid tap water, fountain drinks, and ice cubes. Wash your hands often with soap and clean water. If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol).

 Clean your hands especially before you eat or prepare food and after using the bathroom. Use bottled, boiled, or chemically treated water to wash dishes, brush your teeth, wash and prepare food, or make ice. Eat foods that are packaged or that are freshly cooked and served hot. Do not eat raw and undercooked meats and seafood or unpeeled fruits and vegetables. Dispose of feces in a sanitary manner to prevent contamination of water and food 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

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.

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.

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.

Epidemiology and Risk Factors 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 nonO139 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 nonO1 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.

A person can get cholera by drinking water or eating food contaminated with the cholera bacterium. Large epidemics are often related to fecal contamination of water supplies or street vended foods. The disease is occasionally transmitted through eating raw or undercooked shellfish that are naturally contaminated.

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.

Simple rehydration treatment saves lives, but 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.

In the U.S., there has been a modest increase in imported cases since 1991 related to travel and ongoing epidemics.

Non-O1 and Non-O139 Vibrio cholerae Infections Vibrio cholerae is a species of bacteria. Some strains of Vibrio cholerae cause cholera, a severe diarrheal illness. Vibrio cholerae has many different types or serogroups, only two of which can cause epidemic cholera. Those two serogroups are called serogroup O1 and serogroup O139 (O139 is found only in Asia) and can cause epidemic cholera if they also produce the cholera toxin. The other serogroups are known collectively as non-O1 and non-O139 Vibrio cholerae. These serogroups can cause a diarrheal disease which is less severe than cholera and does not have epidemic potential.

Non-O1 and non-O139 Vibrio cholerae are the third most commonly reported group of Vibrio bacteria. On the average, around 40 cases of non-O1 and non-O139 Vibrio cholerae were reported to the CDC each year since 2000. Infections are seasonal with a peak in the late summer and early fall, coinciding with the warmest water temperatures.

1. Symptoms of infection People with gastroenteritis caused by non-O1, non-O139 Vibrio cholerae can have symptoms of differing severity ranging from mild diarrhea to severe watery diarrhea. Fever and bloody diarrhea are not typically seen in gastroenteritis due to non-O1, non-O139 Vibrio cholerae infection. Sepsis due to non-O1 and non-O139 Vibrio cholerae is seen in immunocompromised people and in people with liver disease. Its symptoms include fevers, chills, and decreased blood pressure (shock). Non-O1 and non-0139 Vibrio cholerae has occasionally been reported to cause wound infections with redness and swelling at the site of infection.

2. How people become infected The non-O1 and non-O139 Vibrio cholerae bacteria have a natural reservoir in sea and coastal waters. In the US, transmission of Vibrio infections is primarily through consumption of raw or undercooked seafood, particularly oysters. Casual contact with an infected person is not a risk for becoming ill. Occasionally, wounds exposed to water containing Vibrio cholerae may become infected.

3. Diagnosis Persons with profuse watery diarrhea should see a health care provider. If the health care provider suspects that the diarrheal illness is due to a Vibrio bacteria, he or she may request a stool sample for culture. The laboratory will then be able to determine if Vibrio cholerae is present and the serogroup to which it belongs.

4. Treatment Diarrhea caused by Vibrio cholerae is treatable, primarily by rehydration, and antibiotic therapy. The most important treatment is to replace the fluids and electrolytes that have been lost due to diarrhea. This is done either through oral fluid rehydration or, in severe cases, intravenous fluid rehydration. In many cases, antibiotics are used to hasten the recovery, but they do not take the place of early and appropriate rehydration therapy. Wounds exposed to seawater should be washed with soap and water as soon as possible, and infected wounds should be evaluated by a health care provider. Wounds that become infected and sepsis should be treated with antibiotics.

5. Recovery Infections with non-O1 and non-O139 Vibrio cholerae are acute illnesses, and those who recover should not expect long-term consequences.

6. Vaccine At this time no vaccine exists for infections with non-O1 and non-O139 Vibrio cholerae.

Disease Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae and is transmitted by contaminated food or water. The infection is often mild or without symptoms, but sometimes it can be severe.

A young boy being checked for dehydration Approximately 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.

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.

Person washing hands

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.

Diagnosis and Testing Vibrio cholerae growing on thiosulphate citrate bile salt sucrose (TCBS) agar plates Electron micrograph Vibrio cholera of

Cholera is confirmed through culture of a stool specimen or rectal swab.

Cary Blair media is ideal for transport, and the selective thiosulfatecitratebile 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.

Prevention and Control 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 be aware of the basic cholera facts and observe five basic cholera prevention recommendations.

What is Cholera Disease? Cholera disease causes a lot of watery diarrhea and vomiting Cholera diarrhea can look like cloudy rice water Cholera can cause death from dehydration (the loss of water and salts from the body) within hours if not treated

A cholera treatment center

How is Cholera Spread? Cholera germs are found in the feces (poop) of infected people Cholera is spread when feces (poop) from an infected person gets into the water people drink or the food people eat Cholera is not likely to spread directly from one person to another

What to do if you think that you or someone in your family has cholera 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

Five Basic Cholera Prevention Messages 1. 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 2. 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 childs 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. 3. 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 dont 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 4. 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. 5. Clean up safelyin 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 source