Cholera primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

Overview

Primary prevention of cholera can be achieved on an individual level by appropriate personal hygiene, use of sanitary water supply, appropriate preparation of food, as well as prompt identification, isolation, and treatment of cases. Primary preventive methods may also be implemented on a community level through effective water sanitation, appropriate and broad vaccination of the community to develop herd immunity as well as early detection of an outbreak.

Primary Prevention

Individual Prevention

Effective methods for individual primary prevention of cholera include:

• Practice appropriate hand washing and personal hygiene
• Avoid defecation in bodies of water
• Appropriate preparation and cooking of food (e.g., seafood)
• Peeling of fruits and vegetables
• Use of sanitary water supply

Prevention in the Community

Primary prevention of cholera in the community include:

• Broad vaccination of the community for herd immunity
• Sickbed: Isolate the severe cases. Proper disposal and treatment of the germ-infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
• Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
• Education: Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.

Prevention in Healthcare settings

Primary Prevention in a health care setting includes appropriate sanitation of potentially infected surfaces and equipment as follows:

• 2% chlorine
  • Made by mixing 3 parts water and 2 parts bleach
  • Used for disinfecting vomit, feces, and corpses
• 0.5% chlorine
  • Made by mixing 9 parts water and 1 part bleach
  • Used for foot baths, cleaning floors, bedding, latrines
• 0.05% chlorine
  • Made by mixing 9 parts water and 1 part 0.5% chlorine solution
  • Used for bathing soiled patients, handwashing, rinsing dishes, laundry

Vaccine

A number of safe and effective oral vaccines for cholera are available. Dukoral, an orally administered, inactivated whole cell vaccine, has an overall efficacy of about 52% during the first year after being given and 62% in the second year, with minimal side effects. It is available in over 60 countries. However, it is not currently recommended by the Centers for Disease Control and Prevention (CDC) for most people traveling from the United States to endemic countries. ShanChol is another oral vaccination which is based on the O1 and O139 serotypes.. An injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old. However, as of 2010, it has limited availability. Work is underway to investigate the role of mass vaccination. The World Health Organization (WHO) recommends immunization of high risk groups, such as children and people with HIV, in countries where this disease is endemic. If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment.

Signals of an Outbreak

Increase number of acute diarrhea cases and patients having common symptoms:

• Watery diarrhea, dehydration and vomiting
• Cases from same area or location
• Eaten the same food (e.g., at a burial ceremony)
• Sharing the same water source
• Outbreak in the neighboring community

Risk for travellers

Risk for travellers is low even in epidemic regions. However, humanitarian relief workers in disaster areas and refugee camps may be at risk.

General precautions

• Cholera vaccination is not required as a condition of entry to any country.
• Avoid drinking or eating unsafe water or foods.

Vaccine

• Oral vaccine consisting of killed whole-cell V. cholerae O1 in combination with a recombinant B-subunit of cholera toxin (WC/rBS).
• Primary immunization consists of two oral doses ≥7 days (but <6 weeks) apart for adults and children aged 6 years and over.
• For children aged 2–5 years, three doses are recommended.
• Following primary immunization, protection against cholera may be expected after about 1 week.
• The vaccine is not licensed for children under 2 years of age.

Summary of vaccine data

	Considerations
Type of vaccine	Killed oral O1 whole-cell with Bsubunit.
	Killed oral O1 and O139.
Number of doses	Two doses (minimum 1 week and maximum 6 weeks apart). Three doses for children aged 2–5 years (minimum 1 week and maximum 6 weeks apart)
	Two doses 14 days apart for individuals aged ≥2 years. One booster dose is recommended after 2 years.
Contraindications	Hypersensitivity to previous dose.
Adverse reactions	Mild gastrointestinal disturbances.
Before departure	2 weeks.
Indication	Travellers at high risk (e.g. emergency/relief workers).