The World Health Organization (WHO) has updated its fact sheet on cholera.

Background Information:

Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. There are many serogroups of V. cholerae, but only two – O1 and O139 – cause outbreaks. V. cholerae O1 has caused all recent outbreaks. There is no difference in the illness caused by the two serogroups.

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.

Cholera affects both children and adults and can kill within hours if untreated.

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.

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 a country where cholera does not regularly occur, an outbreak is defined by the occurrence of at least 1 confirmed 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.

Key Messages:

Every year, there are roughly 1.3 to 4.0 million cases, and 21 000 to 143 000 deaths worldwide due to cholera. During 2017, a total of 1 227 391 cases were notified from 34 countries, including 5654 deaths.

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.

Most of those infected will have no or mild symptoms and can be successfully treated with oral rehydration solution. 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.

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.

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.

Provision of safe water and sanitation is critical to control the transmission of cholera and other waterborne diseases.

Health education campaigns, adapted to local culture and beliefs, should promote the adoption of appropriate hygiene practices such as hand-washing with soap, safe preparation and storage of food and safe disposal of the faeces of children. Funeral practices for individuals who die from cholera must be adapted to prevent infection among attendees.

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).

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.

Shanchol™ and Euvichol-Plus® are essentially the same vaccine 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 for three years, while one dose provides short term protection.

Safe 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.

A global strategy on cholera control with a target to reduce cholera deaths by 90% was launched in 2017.

Useful Links:

Link to the updated fact sheet:

https://www.who.int/news-room/fact-sheets/detail/cholera

Link to WHO position paper on Oral Cholera Vaccines 2017 (English) [PDF]:

http://apps.who.int/iris/bitstream/handle/10665/258763/WER9234.pdf?sequence=1

Link to WHO’s roadmap to ending cholera by 2030 (English) [PDF]:

Click to access global-roadmap.pdf