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Cholera epidemics claim many lives every year in underdeveloped and developing countries. It is an infection caused by the bacterium Vibrio cholerae that mostly affects the small intestine.
Causes and Risk Factors of Cholera
Cholera is an acute diarrheal illness that is caused by the ingestion of contaminated (containing human feces) food or water. The causative agent at the base of this intestinal infection is a toxigenic bacterium called Vibrio cholerae.
Cholera infections may be asymptomatic to severe infections resulting in death from vascular collapse. Cholera infections are predominantly an acute infection; however, in certain areas (parts of Africa and Southeast Asia), cholera infections are chronic in nature.
The bean-shaped pathogen has a long tail attached to it, which it uses for self-propulsion. This particular bacteria spread from person to person through the fecal-oral route, wherein the infectious agents present in the contaminated stool of an infected person find their way into the body of another through ingestion by mouth.
A number of devastating epidemics have been associated with the fecal contamination of water supplies or street-vended foods.
The characteristic pathology of this disease can be traced back to a specific toxin released by the cholera bacteria that is known to target the receptors in the small intestine. The exotoxin creates a secretory response within the small intestines. Hence, cholera is often manifested by profuse watery diarrhea.
Anyone can contract this infection by drinking water or eating food that is contaminated with the cholera bacterium, but it is especially common in children under the age of 5. Within a week of ingesting the bacteria, the symptoms will start showing, which can range from mild to severe.
The following factors can increase your risk of contracting the cholera bug:
- Uncontrolled water sources such as wells, lakes, ponds, streams, and rivers are open to fecal contamination and are usually teeming with the cholera virus.
- Ingestion of contaminated food and drinks is the primary mode of transmission for the cholera bacteria. Even cooked food can become infected with the bacteria through contaminated hands and/or flies. Similarly, fruits and vegetables that are washed with contaminated water pose a threat of spreading the infection. Contaminated shellfish are also sources of cholera infections.
- Babies that are bottle-fed are at a greater risk of cholera than breastfed babies.
- Your blood group may have a bearing on your susceptibility to cholera and other diarrheal infections as well. The risk of contracting this infection is highest for people who fall into the O blood group, whereas those with type AB are the most resistant. Between the two remaining blood types that fall in the middle, people with type A blood are more resistant than those who figure in type B.
- Some people are more vulnerable to cholera due to genetic factors, such as variants in the innate immunity protein BPIFB1 (LPLUNC1).
- Decreased gastric acidity due to the excessive use of antacids can make one prone to cholera. The acidic environment of the stomach often kills the Vibrio. However, the excessive use of antacids (alkali) neutralizes the acidic environment within the stomach, promoting bacterium growth.
- People with compromised immunity, due to malnourishment, certain drugs, or preexisting conditions, are at a greater risk of contracting this infection.
Signs and Symptoms of Cholera
The symptoms of cholera will start showing within a week of ingesting the bacteria and can range from mild to severe.
Watery diarrhea is the most common symptom of cholera, which can lead to dehydration and other serious conditions if not treated in a timely manner.
The majority of the associated symptoms are related to dehydration and subsequent vascular collapse related to the inability to not match the fluid intake with the loss of fluid from diarrhea.
In some cases, individuals are known to have greater than 2 liters (2000 cc) or more of fluid loss through diarrhea.
The associated symptoms include:
- Stomach cramps
- Dry mouth
- Dry skin
- Muscle cramps
- Nausea
- Vomiting
- Low blood pressure
- Exhaustion
- Weakness
- Restlessness
First Line of Treatment for Cholera
Disclaimer: The treatment of cholera is in accordance with the recommendation of the Centers for Disease Control and Prevention (CDC). (1) Endemic areas may benefit for up to 6 months from a vaccine against Vibrio cholerae.
1. Rehydration therapy
This is the first and foremost step toward recovery, which involves the prompt restoration of lost fluids and salts to prevent dehydration and further complications.
2. Antibiotic treatment
This is usually recommended for severely ill cholera patients, in conjunction with the standard hydration therapy.
Antibiotics help to reduce the fluid requirements as well as the duration and intensity of the illness. They are particularly useful for patients who are severely or moderately dehydrated and continue to pass a large volume of stool during rehydration treatment.
Antibiotic treatment is also recommended for all patients who are hospitalized. The preferred choice of antibiotic medicine for cholera treatment depends upon the local antibiotic susceptibility patterns.
However, in most parts of the world, doxycycline is generally recommended as first-line treatment for adults and azithromycin for children and pregnant women.
3. Zinc supplementation
This has also shown to be an effective treatment strategy for the improvement of cholera symptoms in children. Doctors usually recommend 10–20 mg of zinc per day to be started immediately for a speedy recovery from cholera.
Oral or Intravenous Hydration: The Mainstay of Cholera Treatment
Rehydration with ORS (oral rehydration salts) fluids has been upheld as the primary treatment for cholera by the CDC as well as every other credible medical agency in the world.
ORS fluids comprise glucose and electrolytes to make up for the relentless loss of body fluids that is characteristic of cholera; they work to instantly re-energize severely dehydrated bodies.
Sugar-based fluid therapy relies on the fact that for every molecule of glucose absorbed, there is a molecule of water/sodium/potassium transported with the glucose across the small intestinal tract. These life-saving solutions often come in prepackaged containers and are commercially available worldwide.
The CDC follows the guidelines developed by the World Health Organization (WHO):
Treatment volume guidelines; age and weight.
WHO Fluid Replacement or Treatment Recommendations (as per the CDC)
| Patient condition | Treatment | |
|---|---|---|
| No dehydration | Oral rehydration salts | Children <2 years: 50 mL–100 mL, up to 500 mL/day |
| Children 2–9 years: 100 mL–200 mL, up to 1,000 mL/day | ||
| Patients >9 years: As much as wanted, to 2,000 mL/day | ||
| Some dehydration | Oral rehydration salts (amount in first four hours) | Infants <4 months (<5 kg): 200–400 mL |
| Infants 4 months–11 months (5 kg–7.9 kg): 400 mL–600 mL | ||
| Children 1 year–2 years (8 kg–10.9 kg): 600 mL–800 mL | ||
| Children 2 years–4 years (11 kg–15.9 kg): 800 mL–1,200 mL | ||
| Children 5 years–14 years (16 kg–29.9 kg): 1,200 mL–2,200 mL | ||
| Patients >14 years (30 kg or more): 2,200 mL–4,000 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 2 1/2 hours |
- Repeat once if the radial pulse is still very weak or not detectable.
- Reassess the patient every 1 to 2 hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly; 200 mL/kg or more may be needed during the first 24 hours of treatment. (2)
- 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.
As cholera is highly contagious, you need to take precautions to stop the spread of the infection and get proper treatment. Also, you can use a number of home remedies to help treat the symptoms and promote quick recovery.
Tips and Remedies to Get Relief From Cholera
Note: Do consult your doctor for the proper diagnosis and treatment of this condition. Use home remedies only as an adjunct treatment.
Here are some home remedies for cholera.
1. Increase your fluid intake
The first step in treating cholera should be rehydration. Due to diarrhea, there is a high chance of becoming dehydrated and this can worsen your condition.
So, drink lots of water to keep your body hydrated. But not just any water, you need to drink bottled water or water purified with iodine or chlorine. To be on the safe side, boil your water before drinking it.
Along with water, you can also drink coconut water, buttermilk, herbal tea, or orange juice throughout the day. The addition of sugar (sugar cubes, honey, etc.) and salt (bouillon cubes) to water greatly facilitates water reabsorption within the intestinal lumen.
2. Take zinc supplements
A 2008 study done in Bangladesh found that zinc supplements are beneficial in reducing the duration and severity of cholera in children. There are more than 200 human zinc enzymes that help fight off infection and boost the immune system. (3)
Additionally, zinc appears to inhibit Vibrio attachment to intestinal receptors. This is the same reasoning as to why zinc lozenges can be effective with early intervention in viral/cold syndromes.
How to consume:
- WHO and UNICEF recommend 10 to 20 mg of zinc per day for children with diarrhea due to cholera.
- Also, include foods high in zinc such as spinach, brown rice, sesame seeds, pumpkin seeds, lentils, and garlic in your diet.
3. Sip on a lemon solution
Lemon is also helpful in treating cholera due to its antibacterial property. It helps destroy the harmful bacteria within the stomach by enhancing the acidic environment.
Lemon stimulates salivary gland secretions, helping retard dry mouths. Plus, the vitamin C in lemon boosts the immune system to speed up recovery. (4)(5)
How to consume:
- Mix the juice of half a lemon in 1 glass of water.
- Add a little honey and salt and stir the ingredients well.
- Drink the solution at regular intervals until you recover completely.
Note: Do not give honey to children under 1 year of age.
4. Add ginger to your diet
Being a natural antibiotic, ginger helps fight cholera infections. It can also help get rid of diarrhea, stomach cramps, and abdominal pain. (6)
How to consume:
- Grate a small piece of ginger and mix it with 1 teaspoon of honey. Eat the mixture to improve your digestive process.
- Alternatively, you can make ginger tea. Add thin slices of a small piece of ginger to 1 cup of water. You can add a few black peppers, holy basil leaves, and mint leaves. Boil the water for a few minutes, strain the liquid, and add some honey to it. Drink a few cups of this herbal tea daily until you see improvement.
Note: Avoid ginger if you are taking blood thinners.
5. Incorporate onion in your diet
According to Ayurveda, onion is also effective in cholera infections. Onion has antibacterial, antibiotic, and antiseptic properties. Plus, it helps relieve symptoms such as dry mouth, restlessness, and thirst. (7)
How to consume:
- Prepare a paste with half an onion and 7 or 8 black peppers. Divide this paste into three doses, and have it three times daily for a week.
- Alternatively, mix 2 teaspoons each of white onion juice and bitter gourd juice. Add 1 teaspoon of lemon juice to it. Drink this two times daily to recover quickly
6. A probiotic dose of yogurt
Probiotic yogurt is also effective in curing diarrhea in cholera. It contains healthy bacteria that promote digestion and help fight off the Vibrio bacterium. Plus, probiotic yogurt is thought to be good for your immune system. (8)
How to consume:
- Eat 2 to 3 cups of plain probiotic yogurt daily until you get relief. You can add some banana slices to it for added benefit.
- You can also make a tasty smoothie with yogurt and drink it several times a day for faster recovery.
7. Drink turmeric solution
In Ayurvedic medicine, turmeric is often recommended for the treatment of diarrhea, one of the most common symptoms of cholera. (9)
How to use:
- Soak 1 tablespoon of raw turmeric root pieces in lemon juice for 2 hours.
- Remove the turmeric pieces and dry them in the sun.
- Grind the dried pieces into a powder and store it in an airtight container.
- Add ¼ teaspoon of this powder and a little honey to 1 cup of hot water.
- Drink this turmeric solution twice daily until you recover completely.
Note: Be sure not to take high doses of turmeric, which can make your diarrhea worse. Furthermore, the National Institutes of Health has shown that turmeric has blood thinning effects.
Do not use this remedy if you are on anticoagulants or take NSAIDs (such as Motrin, Advil, and Aleve) on a chronic basis. Turmeric should be avoided at any stage of pregnancy.
8. Trust the healing potential of guava roots
The root bark of guava makes for a great healing agent for the natural treatment of cholera, all thanks to its significant antibacterial effects. (10)
It is rich in complex polyphenolic compounds known as tannins that work as free radical scavengers and can be successfully used in the form of a concentrated decoction.
In order to extract the beneficial essence of guava roots to cure cholera symptoms:
How to use:
- Simply mix 30 grams of guava root powder in half a liter of water and boil the same so it reduces to one-third of its original volume.
- Drink this concentrated decoction twice a day until your condition improves.
9. Drink bitter gourd tonic
The much-talked-about pharmacological virtues of bitter gourd account for its efficacy in the treatment of early-stage cholera. This is further corroborated by a 2017 study published in Research & Reviews: A Journal of Biotechnology. (11)
Perhaps the most notable health benefit attributed to bitter gourd is its ability to cleanse the liver and regenerate the liver cells. Additionally, the fresh juice extracted from the leaves of bitter gourd has been traditionally used in antiviral and antibacterial herbal therapy.
How to consume:
- Cholera patients can benefit from drinking a tonic made with 1 teaspoon of fresh bitter gourd juice mixed with an equal quantity of white onion juice and a ½ teaspoon of lime juice.
- Please be reminded that bitter gourd can induce miscarriages, induce hypoglycemia, induce cardiac dysrhythmias, and induce hepatic inflammation and should be avoided in children.
Vaccine for Cholera (WHO Recommendation)
Immunization against cholera is perhaps the safest and most effective preventive step against this rather common diarrheal infection. In countries or areas ravaged by cholera outbreaks, vaccines alone have provided as much as 66%–67% protection against clinically significant cholera for a period of 6 months to at least 2 years.
For adults and children aged 6 years or above, two oral doses are administered 7–14 days apart as part of primary immunization against cholera. Younger children aged 2–5 years, on the other hand, are given three doses.
Typically, the person getting vaccinated is asked to swear off food and drinks for 1 hour before and after the immunization. In the event that the second dose gets delayed for more than 6 weeks, you will have to redo the entire process, beginning with the first dose again.
You can expect the vaccine to start working and offer protection about a week after the primary immunization is completed.
For adults and children aged 6 years or more, one booster dose is recommended 2 years after the primary immunization. For children between the ages of 2 and 5 years, the booster dose is administered every 6 months after the initial immunization.
The cholera vaccine is not advised for children below the age of 2 years.
Types of vaccine:
- Oral killed whole cell O1 with B subunit
- Oral killed O1 and O139
Preventive Tips for Cholera
- Drink filtered or boiled water.
- Store water and food in closed containers to prevent contamination.
- Wash your hands before cooking or eating.
- Follow a very light diet for 1 to 2 weeks after resolution of the cholera infection.
- Avoid spicy, oily, and junk foods.
- Avoid milk and other dairy products, especially if you have lactose intolerance.
- Take a hot bath once or twice daily to keep your body warm.
- To prevent vomiting, suck on a small piece of ice or ginger candies.
- Apply cold compresses on the stomach to get relief from stomach cramps and abdominal pains.
- As prevention is always better than cure, be vaccinated against cholera.
Complications Regarding Cholera
Nearly 10% of all cholera cases are classified as severe and are characterized by profuse watery diarrhea, vomiting, and leg cramps. People with such serious symptoms can suffer a heavy and rapid loss of body fluids and electrolytes, which must be addressed readily.
In the absence of timely treatment, the patient is likely to experience extreme dehydration and shock. If the condition continues to worsen, it can turn fatal within a matter of hours.
The statistics released by the CDC highlight the intensity and magnitude of this ailment. An estimated 2.9 million cases of cholera are reported each year around the world, of which around 95,000 result in death. If these numbers are anything to go by, you should know better than to take this infection lightly. (12)
Severe diarrhea is perhaps one of the most serious complications of cholera, which can render you severely dehydrated. Other complications include:
- Low blood sugar
- Low potassium, magnesium, calcium, and phosphorous levels
- Disturbances of acid-base equilibrium within the body
- Kidney failure
When to See a Doctor
If you think you may have been exposed to cholera and you experience watery stools, seek treatment right away. Severe dehydration, whether it is in a child or an adult, is a medical emergency and should not be ignored.
Expert Answers (Q&A)
Answered by Dr. Renae Thomas, MD (Family Medicine)
Cholera, a diarrheal illness caused by the bacteria called Vibrio cholerae, predominately affects those in resource-limited settings with inadequate access to clean water and sanitation, infecting an estimated 3 million individuals per year, and causing about 100,000 deaths annually.
The infection is rare in the United States of America, and other industrialized cities, but occasionally people become ill from raw, inadequately cooked, or contaminated shellfish and seafood. (13)
Typical symptoms of cholera infection include stomach pain and rumbling, nausea and vomiting, with fevers being uncommon. The diarrhea caused by cholera contains a good number of the Vibrio cholerae bacteria, and it has the potential to affect other people, if ingested or if the bacteria spread to water or food.
So high levels of sanitation are important to reduce the spread of cholera. It is extremely important to properly dispose of diarrhea and vomit from an infected person, regularly wash hands, and sanitize any contaminated items.
Once recovered, people do not carry the disease, and also do not have immunity, meaning they can be reinfected if exposed to the bacteria again. The disease does not typically spread from person to person through casual contact.
Cholera has an incubation period (or asymptomatic period) after infection, lasting between hours to five days before symptoms start. People then develop diarrhea (loose and frequent stools) and sometimes nausea and vomiting, of varying degrees.
The significant loss of fluid and electrolytes in severe cholera (very watery or ‘rice-water’ stools), which can reach up to one liter per hour, with high levels of sodium and potassium, distinguishes cholera from other diarrheal illnesses.
The diarrhea is usually most severe for the first two days and ends after about four to six days, so long as the infected person received treatment with adequate fluid rehydration.
Vibrio cholerae is primarily acquired by eating contaminated food or drinking contaminated water, but it can also be transferred from person to person, via bacteria passing from a sick individual into their stools (fecal-oral transmission). It is not believed that cholera transfers through the air (airborne transmission).
It can be. Vibrio cholerae infection causes a wide variety and levels of illness, from no symptoms whatsoever to severe diarrhea (loose and frequent stools). About one in ten people infected will experience severe cholera.
Within just hours after infection, severe cases of cholera can cause large volumes of fluid and electrolyte losses in the stool (poop), which can lead to hypovolemic shock, which is when the body fluid levels are too low and the body cannot function optimally. Kidney failure from low urine output may also occur. Affected children may also show very low blood sugar levels and experience hypoglycemia or even coma.
The mortality rate (or risk of death) from severe cholera can be up to 10% of those infected, but is reduced to less than 0.5% with prompt fluid rehydration and medical care. Untreated cholera mortality can reach 50–70%. Those more likely to have severe symptoms are those at the extremes of age (those under age 5 and the elderly), those with compromised immune systems, those with blood type O, low stomach acid, those who have had stomach surgery, and/or retinol deficiency.
When appropriately treated, there is rarely any long-term complication although, like other forms of childhood diarrhea, there is a risk of chronic intestinal problems and malnutrition. (13)
Vibrio cholerae is a diverse bacterial species, with only certain strains (the toxin-producing ones), able to cause the illness known as cholera. Of the known 200 strains/groups of Vibrio cholerae, only two are known to cause large outbreaks. The World Health Organization (WHO) recommends cholera vaccines in cholera infection prone areas, in conjunction with prevention, control and treatment strategies.
Research is ongoing for vaccine effectiveness; however early data suggests that it is effective in reducing the risk of cholera. There are four vaccines currently available in various countries, which cover the two strains +/- toxins that cause illness in humans. The vaccine appears to provide protection for at least five years, so far in 42–87% of people, with herd protection occurring when a large percentage of the population is vaccinated.
Efficacy for children under five has only been shown for the vaccine with toxin component included. In the USA, the oral vaccine Vaxchora prevents one of the two types of illness-causing cholera bacteria, and is approved for adult travelers aged 18–64 years. This vaccine is considered about 80–90% effective and should be taken at least ten days prior to travel, away from any antibiotic use, on recommendation from your doctor. (13)
Drinking un-boiled or untreated water is a risk factor for cholera infection. Water can be considered safe to drink if it is treated with chlorine, iodine, filtration, or boiled.
Final Word
Most travelers are at low risk for cholera, but selected travelers, such as healthcare workers working in displaced populations, crowded camps, and areas with poor sanitation, may benefit from vaccination before traveling. Always look at the CDC travel guide website and consult with travel clinic or medical doctor prior to traveling. (14)
If you do become infected, early rehydration with oral rehydration solution (ORS), especially a reduced osmolar ORS is critical. Seek medical help early, as you may need intravenous fluids and/or antibiotics. As tolerated, resume eating as soon as fluid rehydration is achieved to ensure optimal nutrition for healing and recovery.
There is some evidence that supplementary zinc and vitamin A can be useful for children, whilst symptoms are present, on advice from your doctor. The main prevention strategies are clean water and good sanitation. Breastfeeding is also associated with protection in infants. For those in low resource areas, filtering water through a sari cloth prior to drinking can prevent infection from water sources.
When traveling to a cholera-affected area, it is important to follow precautions for the prevention of ‘traveler’s diarrhea,’ such as avoiding tap water, not eating ‘street-food’ or raw/undercooked seafood or raw vegetables, eating only fruits that can be peeled, and treating water with chlorine, iodine, filtration, or boiling.
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