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Disease: Cholera Cholera
Category: Infectious diseases
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Disease Definition:

Cholera is a bacterial disease that usually spreads through contaminated water, resulting in severe dehydration and diarrhea, which may be fatal in a matter of hours in the case of leaving it untreated.
In industrialized countries, modern sewage and water treatment have virtually eliminated cholera. However, in India, Latin America, sub-Saharan Africa, the Middle East and Asia, cholera is still present. When natural disasters, war or poverty force people to live in crowded conditions without adequate sanitation, the risk of cholera epidemic is at its zenith.
Severe dehydration is the cause of death, which can be prevented with a simple and inexpensive rehydration solution. Cholera is treated easily.

Work Group:

Prepared by: Scientific Section

Symptoms, Causes


Mild to moderate diarrhea that is often hard to distinguish from diarrhea caused by other problems is the result of most symptomatic cases of cholera. Most people exposed to the cholera bacterium (called Vibrio cholera) don't become ill and never know they've been infected, however, they can still infect others because they shed cholera bacteria in their stool for seven to 14 days.

The typical signs and symptoms of cholera, which include the following, may develop in only about one in 10 infected people:

Nausea and vomiting:
Vomiting, which occurs in both the early and later stages of cholera, may continue for hours at a time.

One of the most serious complications of cholera dehydration is hypovolemic shock, which happens when a drop in blood pressure and a corresponding reduction in the amount of oxygen reaching the tissues result from low blood volume. Untreated severe hypovolemic shock may result in death in a matter of minutes.

Muscle cramps:
This is caused by the rapid loss of salts such as potassium, chloride and sodium.

Severe, watery diarrhea:
The signs and symptoms of cholera usually start one to five days after the infection, which is the short incubation time for cholera. Diarrhea caused by cholera comes suddenly, and is often voluminous, flecked with mucus and dead cells, and has a milky, pale appearance that looks like water in which rice has been rinsed (rice-water stool). The loss of large amounts of fluid in a short time, about a quart (.95 liters) an hour, is the thing that makes cholera diarrhea so deadly.

Dehydration, which can range from mild to severe depending on the amount of body fluids that have been lost, develops far more quickly with cholera than with other diarrheal diseases and within hours after the onset of cholera symptoms. Severe dehydration means a loss of 10 percent or more of total body weight. The signs and symptoms of cholera dehydration include:

  • Low blood pressure
  • Dry, shriveled skin that's slow to bounce back when pinched into a fold
  • An irregular heartbeat (arrhythmia)
  • Lethargy
  • A dry mouth
  • Little or no urine output
  • Sunken eyes
  • Irritability
  • Extreme thirst

Children with cholera generally have the same signs and symptoms that adults may get; however, children may experience convulsions, fever and extreme drowsiness or even coma.
If someone thinks that they have been exposed to cholera and experiences diarrhea, they should seek immediate treatment, especially if the diarrhea is severe. Immediate care is required in the case of severe dehydration because it is a medical emergency. However, a person is not likely to be infected when following food safety recommendations. Though in industrialized nations the risk of cholera is slight, but sporadic cases of cholera occur throughout the world.


Even though cholera bacteria may harbor because of uncooked vegetables and fruits, raw shellfish and other foods, but the main source of cholera infection is contaminated water supplies.

Vibrio choleare, which is the bacterium that causes cholera, has two distinct life cycles, one in the environment and one in humans.

In coastal waters, where cholera bacteria attach to tiny crustaceans called copepods, cholera bacteria occur naturally. A single crustacean may have as many as 10,000 bacteria stuck on it. Spreading worldwide as the crustaceans follow their food source, the cholera bacteria travel with their hosts. The urea that exists in sewage and in agricultural runoff fuels the growth of algae.   
Ocean surface temperatures and algae blooms are at their height in spring and fall, which is the same time that most cholera outbreaks occur. The existence of more copepods is caused by more algae, and the existence of more bacteria is caused by more copepods.

Humans can excrete the bacteria in their stool and pass cholera disease to others through the fecal-oral route, when they ingest cholera bacteria, even though they may not become sick themselves. When human feces contaminate food or water supplies, this way of passing cholera disease occurs; these can serve as ideal breeding grounds for the cholera bacteria. Fortunately, cholera usually isn't transmitted through casual person-to-person contact. To cause the illness, more than a million cholera bacteria (about the amount one would find in a glass of contaminated water) is needed.

Here are the most common sources of cholera infection:

Surface or well water:
Communities without adequate sanitation and areas affected by natural disasters or war are the places where cholera epidemics are most likely to occur. The risk of being infected with cholera is higher in people living in crowded refugee camps. Contaminated public wells are frequent sources of large-scale cholera outbreaks, and cholera bacteria may stay in water for a long time.

One may be exposed to cholera bacteria through eating raw or undercooked seafood, shellfish in particular, that originates from certain locations, concentrating the levels of cholera bacteria. Shellfish filter large amounts of water, that's why they are a particular problem.

Raw fruits and vegetables:
In areas where cholera is endemic, raw, unpeeled vegetables and fruits are a frequent source of cholera infection. The products of a field may be contaminated by irrigation water containing raw sewage or uncomposted manure fertilizers in developing nations. During processing or harvesting, vegetables and fruits may become tainted with cholera bacteria as well.

Grains such as millet and rice that are contaminated after cooking and allowed to remain at room temperature for several hours become a medium for the growth of cholera bacteria in regions where cholera is widespread.

CTX, a potent toxin that bacteria produce in the small intestine, is the cause of the deadly effects of the disease, even though vibrio cholerae is the source of cholera infection. Diarrhea and a rapid loss of fluids and salts (electrolytes) may be the result when the body secretes enormous amounts of water, which in turn may be caused by the interference of CTX with the normal flow of chloride and sodium when CTX binds to the intestinal walls. 
With the exception of infants who derive immunity from nursing mothers who have previously had cholera, everyone may be at risk of having cholera. However, one may become more likely to experience severe signs and symptoms or be more vulnerable to the disease because of the following factors:

Compromised immunity:
One is at greater risk of cholera infection when having compromised immune system for any reason.

Reduced or nonexistent stomach acid (achlorhydria or hypochlorhydria):
Ordinary stomach acid often serves as a first-line defense against infection as cholera bacteria can't survive in an acidic environment. However, people are more likely to develop cholera and have severe signs and symptoms of the disease when they have low levels of stomach acid, and consequently don't have this protection. Stomach acid levels in children and older adults tend to be lower than normal; as well as in people who have untreated Helicobacter pylori infection; who have had gastric surgery; or who are taking antacids, H-2 blockers or proton pump inhibitors for ulcers. The amount of acid the stomach produces may be reduced by H-2 blockers and proton pump inhibitors, and stomach acid may be neutralized with the help of antacids.

Cholera is interrelated with malnutrition. Cholera is more likely to flourish in places where malnutrition is common, such as areas devastated by natural disasters, war or famine, refugee camps and impoverished countries.

Type O blood:
Cholera is twice as likely to develop in people with type O blood and the reason is not really understood.

Household exposure:
When living with someone who has the disease, one is at a significantly increased risk of cholera.



Within two or three hours, the rapid loss of large amounts of fluids and electrolytes may lead to death in the most severe cases, so cholera can quickly become fatal. In less extreme situations, 18 hours to several days after cholera symptoms first appear dehydration and shock may cause death to people who don't receive treatment.

The following problems may occur, even though shock and severe dehydration are the most devastating complications of cholera:

Kidney (renal) failure:
Kidney failure often accompanies shock in people with cholera. In a potentially life-threatening condition, excess amounts of fluids, some electrolytes and wastes build up in the body when the kidneys lose their filtering ability.

Low blood sugar (hypoglycemia):
When blood levels of glucose, the body's main energy source, fall abnormally low, hypoglycemia occurs, which is a common cholera complication in children. After eating, glucose is absorbed directly into the bloodstream and it enters the cells through the action of the hormone insulin. Seizures, unconsciousness and even death may be caused by unusually low blood sugar levels, which happen in the case of severe cholera. People become too ill to eat and they don't get glucose from food.

Low potassium levels (hypokalemia):
Potassium is among the large quantities of minerals that people with cholera lose in their stools. In people whose potassium stores have already been depleted by malnutrition, hypokalemia is particularly serious. Very low levels of potassium interfere with heart and nerve function and are life-threatening.


Because the disease may cause death within hours, cholera requires immediate treatment.

The duration of diarrhea may shorten and vomiting may decrease with the help of a single dose of azithromycin in adults or children with severe cholera.

Using a simple rehydration solution that contains specific proportions of water, salts and sugar, the goal is to replace fluids and electrolytes lost through diarrhea. The solution is available in a form of powder that can be reconstituted in boiled or bottled water. About half the people with cholera die without rehydration, but the number of fatalities drops to less than 1% with treatment.

Zinc supplements:
Zinc may shorten and decrease the duration of diarrhea in children with cholera as proved by research.

Intravenous fluids:
Oral rehydration alone may help most people during a cholera epidemic; however, intravenous fluids may be needed as well in the case of severe dehydration.


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