View source for Medicine:Cholera

{{Short description|Bacterial infection of the small intestine}}
{{Infobox medical condition (new)
| name            = Cholera
| synonyms        = Asiatic cholera, epidemic cholera<ref name=textbook/>
| image           = PHIL 1939 lores.jpg
| caption         = A person with severe [[Medicine:Dehydration|dehydration]] due to cholera, causing sunken eyes and wrinkled hands and skin.
| field           = [[Medicine:Infectious disease (medical specialty)|Infectious disease]]
| symptoms        = Large amounts of watery [[Medicine:Diarrhea|diarrhea]], [[Medicine:Vomiting|vomiting]], muscle cramps<ref name=WHO2010 /><ref name=CDC2015Pro />
| complications   = [[Medicine:Dehydration|Dehydration]], [[Medicine:Electrolyte imbalance|electrolyte imbalance]]<ref name=WHO2010 />
| onset           = 2 hours to 5 days after exposure<ref name=CDC2015Pro />
| duration        = A few days<ref name=WHO2010 />
| causes          = ''[[Biology:Vibrio cholerae|Vibrio cholerae]]'' spread by fecal-oral route<ref name=WHO2010 /><ref name=Fink2016 />
| risks           = Poor [[Engineering:Sanitation|sanitation]], not enough clean drinking water, poverty<ref name=WHO2010 />
| diagnosis       = Stool test<ref name=WHO2010 />
| differential    =
| prevention      = Improved sanitation, clean water, hand washing, [[Medicine:Cholera vaccine|cholera vaccine]]s<ref name=WHO2010 /><ref name=Lancet2012 />
| treatment       = [[Medicine:Oral rehydration therapy|Oral rehydration therapy]], zinc supplementation, intravenous fluids, antibiotics<ref name=WHO2010 /><ref name=CDC2014Zinc />
| medication      =
| prognosis       = Less than 1% mortality rate with proper treatment, untreated mortality rate 50–60%
| frequency       = 3–5&nbsp;million people a year<ref name=WHO2010 />
| deaths          = 28,800 (2015)<ref name=GBD2015De/>
}}

'''Cholera''' ({{IPAc-en|'|k|ɒ|l|ər|ə}}) is an [[Medicine:Infection|infection]] of the [[Biology:Small intestine|small intestine]] by some [[Biology:Strain|strains]] of the [[Biology:Bacteria|bacterium]] ''[[Biology:Vibrio cholerae|Vibrio cholerae]]''.<ref name=Fink2016>{{cite book |last1=Finkelstein |first1=Richard A. |chapter=Cholera, ''Vibrio cholerae'' O1 and O139, and Other Pathogenic Vibrios |pmid=21413330 |id={{NCBIBook2|NBK8407}} |editor1-last=Baron |editor1-first=Samuel |title=Medical Microbiology |date=1996 |publisher=University of Texas Medical Branch at Galveston |isbn=978-0-9631172-1-2 |edition=4th }}</ref><ref name=CDC2015Pro /> Symptoms may range from none, to mild, to severe.<ref name=CDC2015Pro>{{cite web|title=Cholera – Vibrio cholerae infection Information for Public Health & Medical Professionals|url=https://www.cdc.gov/cholera/healthprofessionals.html|publisher=Centers for Disease Control and Prevention|access-date=17 March 2015|date=January 6, 2015|url-status=live|archive-url=https://web.archive.org/web/20150320052724/http://www.cdc.gov/cholera/healthprofessionals.html|archive-date=20 March 2015}}</ref> The classic symptom is large amounts of watery [[Medicine:Diarrhea|diarrhea]] lasting a few days.<ref name=WHO2010 /> [[Medicine:Vomiting|Vomiting]] and muscle cramps may also occur.<ref name=CDC2015Pro /> Diarrhea can be so severe that it leads within hours to severe [[Medicine:Dehydration|dehydration]] and [[Medicine:Electrolyte imbalance|electrolyte imbalance]].<ref name=WHO2010 /> This may result in [[Medicine:Enophthalmia|sunken eyes]], cold skin, decreased skin elasticity, and wrinkling of the hands and feet.<ref name=Lancet2012>{{cite journal | vauthors = Harris JB, LaRocque RC, Qadri F, Ryan ET, Calderwood SB | title = Cholera | journal = Lancet | volume = 379 | issue = 9835 | pages = 2466–2476 | date = June 2012 | pmid = 22748592 | pmc = 3761070 | doi = 10.1016/s0140-6736(12)60436-x }}</ref> Dehydration can cause the skin to turn [[Medicine:Cyanosis|bluish]].<ref>{{cite book|last1=Bailey|first1=Diane  | name-list-style = vanc |title=Cholera|date=2011|publisher=Rosen Pub.|location=New York|isbn=978-1-4358-9437-2|page=7|edition=1st|url=https://books.google.com/books?id=7rvLPx33GPgC&pg=PA7|url-status=live|archive-url=https://web.archive.org/web/20161203190215/https://books.google.com/books?id=7rvLPx33GPgC&pg=PA7|archive-date=2016-12-03}}</ref> Symptoms start two hours to five days after exposure.<ref name=CDC2015Pro />

Cholera is caused by a number of [[Biology:Serotype|types]] of ''Vibrio cholerae'', with some types producing more severe disease than others.<ref name=WHO2010 /> It is spread mostly by unsafe water and unsafe food that has been contaminated with [[Medicine:Human feces|human feces]] containing the bacteria.<ref name=WHO2010 /> Undercooked shellfish is a common source.<ref>{{cite web|title=Sources of Infection & Risk Factors|url=https://www.cdc.gov/cholera/infection-sources.html|publisher=Centers for Disease Control and Prevention|access-date=17 March 2015|date=November 7, 2014|url-status=live|archive-url=https://web.archive.org/web/20150312223337/http://www.cdc.gov/cholera/infection-sources.html|archive-date=12 March 2015}}</ref> Humans are the only known host for the [[Biology:Bacteria|bacteria]].<ref name=WHO2010 /> Risk factors for the disease include poor [[Engineering:Sanitation|sanitation]], insufficient clean drinking water, and poverty.<ref name=WHO2010 /> Cholera can be diagnosed by a stool test,<ref name=WHO2010>{{cite journal | title = Cholera vaccines: WHO position paper | journal = Weekly Epidemiological Record  | volume = 85 | issue = 13 | pages = 117–28 | date = March 2010 | pmid = 20349546 | url =https://www.who.int/wer/2010/wer8513.pdf | url-status = live | archive-url = https://web.archive.org/web/20150413020218/http://www.who.int/wer/2010/wer8513.pdf | archive-date = April 13, 2015 }}</ref> or a rapid [[Engineering:Dipstick#Testing dipstick|dipstick test]], although the dipstick test is less accurate.<ref>{{cite web|title=Diagnosis and Detection|url=https://www.cdc.gov/cholera/diagnosis.html|publisher=Centers for Disease Control and Prevention|access-date=17 March 2015|date=February 10, 2015|url-status=live|archive-url=https://web.archive.org/web/20150315041832/http://www.cdc.gov/cholera/diagnosis.html|archive-date=15 March 2015}}</ref>

Prevention methods against cholera include improved sanitation and access to clean water.<ref name=Lancet2012 /> [[Medicine:Cholera vaccine|Cholera vaccine]]s that are given by mouth provide reasonable protection for about six months, and confer the added benefit of protecting against another type of diarrhea caused by ''[[Biology:Escherichia coli|E.&nbsp;coli]]''.<ref name=WHO2010 /> In 2017 the US Food and Drug Administration (FDA) approved a single-dose, live, oral cholera vaccine called [[Medicine:Cholera vaccine|Vaxchora]] for adults aged 18–64 who are travelling to an area of active cholera transmission.<ref>{{cite web|title=Cholera Fact Sheet|url=https://www.health.ny.gov/diseases/communicable/cholera/fact_sheet.htm|website=www.health.ny.gov|date=2017| access-date=2020-05-26}}</ref> It offers limited protection to young children. People who survive an episode of cholera have long-lasting immunity for at least three years (the period tested).<ref name="immunity">{{cite journal|title=Cholera: Immunity and Prospects in Vaccine Development|last= Harris| first= Jason B| journal=J Infect Dis |date= November 15, 2018 |volume=218 |issue=Suppl 3 |pages=S141–S146 |doi=10.1093/infdis/jiy414 |pmid=30184117 |pmc=6188552 }}</ref>

The primary treatment for affected individuals is [[Medicine:Oral rehydration therapy|oral rehydration salts]] (ORS), the replacement of fluids and electrolytes by using slightly sweet and salty solutions.<ref name=WHO2010 /> Rice-based solutions are preferred.<ref name=WHO2010 /> In children, zinc supplementation has also been found to improve outcomes.<ref name=CDC2014Zinc>{{cite web |title=Cholera – Vibrio cholerae infection Treatment |url=https://www.cdc.gov/cholera/treatment/index.html |publisher=Centers for Disease Control and Prevention |access-date=17 March 2015 |date=November 7, 2014|url-status=live |archive-url=https://web.archive.org/web/20150311042338/http://www.cdc.gov/cholera/treatment/index.html |archive-date=11 March 2015}}</ref> In severe cases, intravenous fluids, such as Ringer's lactate, may be required, and [[Chemistry:Antibiotic|antibiotic]]s may be beneficial.<ref name=WHO2010 /> The choice of antibiotic is aided by [[Biology:Antibiotic sensitivity testing|antibiotic sensitivity testing]].<ref name=CDC2015Pro />

Cholera continues to affect an estimated 3–5&nbsp;million people worldwide and causes 28,800–130,000&nbsp;deaths a year.<ref name=WHO2010 /><ref name=GBD2015De >{{cite journal | title = Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1459–1544 | date = October 2016 | pmid = 27733281 | pmc = 5388903 | doi = 10.1016/s0140-6736(16)31012-1 | last1 = Wang | first1 = Haidong | last2 = Naghavi | first2 = Mohsen | last3 = Allen | first3 = Christine | last4 = Barber | first4 = Ryan M. | last5 = Bhutta | first5 = Zulfiqar A. | last6 = Carter | first6 = Austin | last7 = Casey | first7 = Daniel C. | last8 = Charlson | first8 = Fiona J. | last9 = Chen | first9 = Alan Zian | last10 = Coates | first10 = Matthew M. | last11 = Coggeshall | first11 = Megan | last12 = Dandona | first12 = Lalit | last13 = Dicker | first13 = Daniel J. | last14 = Erskine | first14 = Holly E. | last15 = Ferrari | first15 = Alize J. | last16 = Fitzmaurice | first16 = Christina | last17 = Foreman | first17 = Kyle | last18 = Forouzanfar | first18 = Mohammad H. | last19 = Fraser | first19 = Maya S. | last20 = Fullman | first20 = Nancy | last21 = Gething | first21 = Peter W. | last22 = Goldberg | first22 = Ellen M. | last23 = Graetz | first23 = Nicholas | last24 = Haagsma | first24 = Juanita A. | last25 = Hay | first25 = Simon I. | last26 = Huynh | first26 = Chantal | last27 = Johnson | first27 = Catherine O. | last28 = Kassebaum | first28 = Nicholas J. | last29 = Kinfu | first29 = Yohannes | last30 = Kulikoff | first30 = Xie Rachel | display-authors = 29 }}</ref> To date, seven cholera pandemics have occurred in the developing world, with the most recent beginning in 1961, and continuing today.<ref>{{cite news |title=Cholera's seven pandemics |url=http://www.cbc.ca/news/technology/cholera-s-seven-pandemics-1.758504 |access-date=15 July 2018 |work=CBC |date=9 May 2008}}</ref> The illness is rare in high-income countries, and affects children most severely.<ref name="WHO2010" /><ref>{{cite web|title=Cholera – Vibrio cholerae infection|url=https://www.cdc.gov/cholera/index.html|publisher=Centers for Disease Control and Prevention|access-date=17 March 2015|date=October 27, 2014|url-status=live|archive-url=https://web.archive.org/web/20150317031930/http://www.cdc.gov/cholera/index.html|archive-date=17 March 2015}}</ref> Cholera occurs as both [[Medicine:Epidemic|outbreaks]] and chronically in certain areas.<ref name=WHO2010 /> Areas with an ongoing risk of disease include [[Earth:Africa|Africa]] and [[Place:Southeast Asia|Southeast Asia]].<ref name=WHO2010 /> The risk of death among those affected is usually less than 5%, given improved treatment, but may be as high as 50% without such access to treatment.<ref name=WHO2010 /> Descriptions of cholera are found as early as the 5th century BC in [[Social:Sanskrit|Sanskrit]].<ref name=Lancet2012 /> In Europe, cholera was a term initially used to describe any kind of gastroenteritis, and was not used for this disease until the early 19th century.<ref name="rosenberg"/> The study of cholera in England by John Snow between 1849 and 1854 led to significant advances in the field of [[Social:Epidemiology|epidemiology]] because of his insights about transmission via contaminated water, and a map of the same was the first recorded incidence of epidemiological tracking.<ref name=Lancet2012 /><ref>{{cite book|last1=Timmreck|first1=Thomas C. | name-list-style = vanc |title=An introduction to epidemiology|date=2002|publisher=Jones and Bartlett Publishers|location=Sudbury, MA|isbn=978-0-7637-0060-7|page=77|edition=3.|url=https://books.google.com/books?id=yyrbKemADL4C&pg=PA77|url-status=live|archive-url=https://web.archive.org/web/20161203190442/https://books.google.com/books?id=yyrbKemADL4C&pg=PA77|archive-date=2016-12-03}}</ref> 
[[File:En.Wikipedia-VideoWiki-Cholera.webm|thumb|thumbtime=1:19|upright=1.3|Video summary of this article with VideoWiki (script)]]

== Signs and symptoms ==
[[File:Cholera feces.jpg|thumb|Typical cholera diarrhea that looks like "rice water"]]
The primary symptoms of cholera are profuse [[Medicine:Diarrhea|diarrhea]] and [[Medicine:Vomiting|vomiting]] of clear fluid.<ref name="Lancet2004">{{cite journal | vauthors = Sack DA, Sack RB, Nair GB, Siddique AK | title = Cholera | journal = Lancet | volume = 363 | issue = 9404 | pages = 223–33 | date = January 2004 | pmid = 14738797 | doi = 10.1016/S0140-6736(03)15328-7 | s2cid = 208793200 }}</ref> These symptoms usually start suddenly, half a day to five days after ingestion of the bacteria.<ref>{{cite journal | vauthors = Azman AS, Rudolph KE, Cummings DA, Lessler J | title = The incubation period of cholera: a systematic review | journal = The Journal of Infection | volume = 66 | issue = 5 | pages = 432–8 | date = May 2013 | pmid = 23201968 | pmc = 3677557 | doi = 10.1016/j.jinf.2012.11.013 }}</ref> The diarrhea is frequently described as "rice water" in nature and may have a fishy odor.<ref name=Lancet2004 /> An untreated person with cholera may produce {{convert|10|to|20|litre|USgal|sigfig=1}} of diarrhea a day.<ref name=Lancet2004 /> Severe cholera, without treatment, kills about half of affected individuals.<ref name=Lancet2004 /> If the severe diarrhea is not treated, it can result in life-threatening [[Medicine:Dehydration|dehydration]] and [[Physics:Electrolyte|electrolyte]] imbalances.<ref name=Lancet2004 /> Estimates of the ratio of [[Medicine:Asymptomatic|asymptomatic]] to symptomatic infections have ranged from 3 to 100.<ref>{{cite journal | vauthors = King AA, Ionides EL, Pascual M, Bouma MJ | title = Inapparent infections and cholera dynamics | journal = Nature | volume = 454 | issue = 7206 | pages = 877–80 | date = August 2008 | pmid = 18704085 | doi = 10.1038/nature07084 | s2cid = 4408759 | bibcode = 2008Natur.454..877K | hdl = 2027.42/62519 | hdl-access = free }}</ref> Cholera has been nicknamed the "blue death"<ref name="Greenough">{{cite journal|last1=Greenough|first1=William B. | name-list-style = vanc |title=The blue death Disease, disaster, and the water we drink|pmc=2171164|journal=The Journal of Clinical Investigation|volume=118|issue=1|pages=4|doi=10.1172/JCI34394|date=2 January 2008}}</ref> because a person's skin may turn [[Medicine:Cyanosis|bluish-gray]] from extreme loss of fluids.<ref name=McE2009>{{cite book|author1=McElroy, Ann |author2=Townsend, Patricia K. |title=Medical Anthropology in Ecological Perspective|url=https://archive.org/details/medicalanthropol00mcel_718 |url-access=limited |location=Boulder, CO|publisher= Westview|year= 2009|page= [https://archive.org/details/medicalanthropol00mcel_718/page/n395 375]|isbn=978-0-8133-4384-6}}</ref>

Fever is rare and should raise suspicion for secondary infection. Patients can be lethargic and might have sunken eyes, dry mouth, cold clammy skin, or wrinkled hands and feet. [[Medicine:Kussmaul breathing|Kussmaul breathing]], a deep and labored breathing pattern, can occur because of acidosis from [[Medicine:Human feces|stool]] [[Chemistry:Bicarbonate|bicarbonate]] losses and lactic acidosis associated with poor [[Medicine:Perfusion|perfusion]]. [[Physics:Blood pressure|Blood pressure]] drops due to dehydration, peripheral pulse is rapid and thready, and urine output decreases with time. Muscle cramping and weakness, altered consciousness, seizures, or even [[Medicine:Coma|coma]] due to [[Medicine:Electrolyte imbalance|electrolyte imbalance]]s are common, especially in children.<ref name=Lancet2004 />

== Cause ==
{{Main|Biology:Vibrio cholerae}}
[[File:Cholera bacteria SEM.jpg|thumb|[[Physics:Scanning electron microscope|Scanning electron microscope]] image of ''Vibrio cholerae'']]
[[File:Vibrio cholerae.jpg|thumb|''Vibrio cholerae'', the bacterium that causes cholera]]

=== Transmission ===
Cholera bacteria have been found in shellfish and [[Earth:Plankton|plankton]].<ref name="Lancet2004" />

[[Medicine:Transmission|Transmission]] is usually through the fecal-oral route of contaminated food or water caused by poor [[Engineering:Sanitation|sanitation]].<ref name="WHO2010" /> Most cholera cases in [[Finance:Developed country|developed countries]] are a result of transmission by food, while in [[Finance:Developing country|developing countries]] it is more often water.<ref name="Lancet2004" /> Food transmission can occur when people harvest seafood such as [[Biology:Oyster|oyster]]s in waters infected with [[Earth:Sewage|sewage]], as ''Vibrio cholerae'' accumulates in [[Earth:Plankton|plankton]]ic [[Biology:Copepod|crustaceans]] and the oysters eat the [[Earth:Zooplankton|zooplankton]].<ref name="bakerinstitute.org">{{cite AV media|url=http://bakerinstitute.org/videos/civic-scientist-lecture-series-rita-colwell-oceans-climate-and-health-cholera-model-infectious-diseases-changing-environment/|title=Oceans, Climate, and Health: Cholera as a Model of Infectious Diseases in a Changing Environment|publisher=James A Baker III Institute for Public Policy|people=Rita Colwell|access-date=2013-10-23|location=Rice University|url-status=dead|archive-url=https://web.archive.org/web/20131026030733/http://bakerinstitute.org/videos/civic-scientist-lecture-series-rita-colwell-oceans-climate-and-health-cholera-model-infectious-diseases-changing-environment/|archive-date=2013-10-26}}</ref>

People infected with cholera often have diarrhea, and disease transmission may occur if this highly liquid stool, colloquially referred to as "rice-water", contaminates water used by others.<ref name="Sherris">{{cite book|title=Sherris Medical Microbiology|publisher=McGraw Hill|year=2004|isbn=978-0-8385-8529-0|edition=4th|pages=376–7|editor1=Ryan KJ |editor2=Ray CG}}</ref>  A single diarrheal event can cause a one-million fold increase in numbers of ''V. cholerae'' in the environment.<ref>{{Cite web|url=https://www.niaid.nih.gov/diseases-conditions/cholera-biology-and-genetics|title=Cholera Biology and Genetics {{!}} NIH: National Institute of Allergy and Infectious Diseases|website=www.niaid.nih.gov|date=7 February 2011 |language=en|access-date=2017-12-05}}</ref> The source of the contamination is typically other people with cholera when their untreated diarrheal discharge is allowed to get into waterways, [[Earth:Groundwater|groundwater]] or drinking water supplies. Drinking any contaminated water and eating any foods washed in the water, as well as shellfish living in the affected [[Earth:Waterway|waterway]], can cause a person to contract an infection. Cholera is rarely [[Philosophy:Contagious disease|spread directly from person to person]].<ref name="CDC 2020">{{cite web | title=General Information - Cholera | website=CDC | date=2020-08-05 | url=https://www.cdc.gov/cholera/general/index.html#three | access-date=2021-03-11}}</ref><ref group=note>According to CDC,"The infection [cholera] is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk factor for becoming ill."</ref>

''V. cholerae'' also exists outside the human body in natural water sources, either by itself or through interacting with [[Earth:Phytoplankton|phytoplankton]], [[Earth:Zooplankton|zooplankton]], or [[Chemistry:Biotic material|biotic]] and abiotic detritus.<ref name=NEJOct2009review>{{cite journal | vauthors = Nelson EJ, Harris JB, Morris JG, Calderwood SB, Camilli A | title = Cholera transmission: the host, pathogen and bacteriophage dynamic | journal = Nature Reviews. Microbiology | volume = 7 | issue = 10 | pages = 693–702 | date = October 2009 | pmid = 19756008 | pmc = 3842031 | doi = 10.1038/nrmicro2204 }}</ref> Drinking such water can also result in the disease, even without prior contamination through fecal matter. Selective pressures exist however in the aquatic environment that may reduce the virulence of ''V. cholerae''.<ref name=NEJOct2009review /> Specifically, animal models indicate that the transcriptional profile of the pathogen changes as it prepares to enter an aquatic environment.<ref name=NEJOct2009review /> This transcriptional change results in a loss of ability of ''V. cholerae'' to be cultured on standard media, a phenotype referred to as 'viable but non-culturable' (VBNC) or more conservatively 'active but non-culturable' (ABNC).<ref name=NEJOct2009review /> One study indicates that the culturability of ''V. cholerae'' drops 90% within 24 hours of entering the water, and furthermore that this loss in culturability is associated with a loss in virulence.<ref name=NEJOct2009review /><ref name=NEJOct2008plos>{{cite journal | vauthors = Nelson EJ, Chowdhury A, Flynn J, Schild S, Bourassa L, Shao Y, LaRocque RC, Calderwood SB, Qadri F, Camilli A | display-authors = 6 | title = Transmission of Vibrio cholerae is antagonized by lytic phage and entry into the aquatic environment | journal = PLOS Pathogens | volume = 4 | issue = 10 | pages = e1000187 | date = October 2008 | pmid = 18949027 | pmc = 2563029 | doi = 10.1371/journal.ppat.1000187 | doi-access = free }}</ref>

Both toxic and non-toxic strains exist. Non-toxic strains can acquire [[Medicine:Toxicity|toxicity]] through a [[Biology:Temperateness (virology)|temperate]] [[Biology:Bacteriophage|bacteriophage]].<ref name="Archivist_1997">{{cite journal |title=Cholera phage discovery |journal=Archives of Disease in Childhood |date=1 March 1997 |volume=76 |issue=3 |pages=274 |doi=10.1136/adc.76.3.274 |pmc=1717096 |last1=Archivist }}</ref>

=== Susceptibility ===
About 100{{nbsp}}million bacteria must typically be ingested to cause cholera in a normal healthy adult.<ref name=Lancet2004 /> This dose, however, is less in those with lowered [[Biology:Gastric acid|gastric acid]]ity (for instance those using proton pump inhibitors).<ref name=Lancet2004 /> Children are also more susceptible, with two- to four-year-olds having the highest rates of infection.<ref name=Lancet2004 /> Individuals' susceptibility to cholera is also affected by their [[Biology:Blood type|blood type]], with those with type O blood being the most susceptible.<ref name=Lancet2004 /> Persons with lowered immunity, such as persons with AIDS or [[Medicine:Malnutrition|malnourished]] children, are more likely to develop a severe case if they become infected.<ref name=WHOpreventionandcontrolofoutbreaks>[http://www.emro.who.int/csr/Media/PDF/cholera_whopolicy.pdf Prevention and control of cholera outbreaks: WHO policy and recommendations] {{webarchive|url=https://web.archive.org/web/20111122092541/http://www.emro.who.int/csr/Media/PDF/cholera_whopolicy.pdf |date=2011-11-22 }}, World Health Organization, Regional Office for the Eastern Mediterranean, undated but citing sources from '07, '04, '03, '04, and '05.</ref> Any individual, even a healthy adult in middle age, can undergo a severe case, and each person's case should be measured by the loss of fluids, preferably in consultation with a professional [[Medicine:Health care provider|health care provider]].{{medical citation needed|date=December 2013}}

The [[Medicine:Cystic fibrosis|cystic fibrosis]] genetic [[Biology:Mutation|mutation]] known as delta-F508 in humans has been said to maintain a selective heterozygous advantage: heterozygous carriers of the mutation (who are not affected by cystic fibrosis) are more resistant to ''V. cholerae'' infections.<ref name="Bertranpetit_1996">{{cite book |doi=10.1002/9780470514887.ch6 |chapter=Genetic and Geographical Variability in Cystic Fibrosis: Evolutionary Considerations |title=Ciba Foundation Symposium 197 - Variation in the Human Genome |series=Novartis Foundation Symposia |year=2007 |last1=Bertranpetit |first1=Jaume |last2=Calafell |first2=Francesc |volume=197 |pages=97–118 |pmid=8827370 |isbn=978-0-470-51488-7 }}</ref> In this model, the genetic deficiency in the [[Biology:Cystic fibrosis transmembrane conductance regulator|cystic fibrosis transmembrane conductance regulator]] channel proteins interferes with bacteria binding to the intestinal epithelium, thus reducing the effects of an infection.

== Mechanism ==
[[File:Cholera role of biofilm in intestinal colonization.jpg|thumb|upright=1.4|The role of [[Earth:Biofilm|biofilm]] in the intestinal colonization of ''Vibrio cholerae'']]
When consumed, most bacteria do not survive the [[Biology:Gastric acid|acidic]] conditions of the [[Biology:Stomach|human stomach]].<ref name="BliskaAlmagro-Moreno2015" /> The few surviving bacteria conserve their energy and stored [[Earth:Nutrient|nutrient]]s during the passage through the stomach by shutting down [[Biology:Protein|protein]] production. When the surviving bacteria exit the stomach and reach the [[Biology:Small intestine|small intestine]], they must propel themselves through the thick [[Biology:Mucus#Digestive system|mucus]] that lines the small intestine to reach the intestinal walls where they can attach and thrive.<ref name="BliskaAlmagro-Moreno2015">{{cite journal | vauthors = Almagro-Moreno S, Pruss K, Taylor RK | title = Intestinal Colonization Dynamics of Vibrio cholerae | journal = PLOS Pathogens | volume = 11 | issue = 5 | pages = e1004787 | date = May 2015 | pmid = 25996593 | pmc = 4440752 | doi = 10.1371/journal.ppat.1004787 | doi-access = free }}</ref>

Once the cholera bacteria reach the intestinal wall, they no longer need the [[Biology:Flagellum|flagella]] to move. The bacteria stop producing the protein flagellin to conserve energy and nutrients by changing the mix of proteins that they express in response to the changed chemical surroundings. On reaching the intestinal wall, ''V. cholerae'' start producing the [[Biology:Exotoxin|toxic proteins]] that give the infected person a watery diarrhea. This carries the multiplying new generations of ''V. cholerae'' bacteria out into the drinking water of the next host if proper sanitation measures are not in place.<ref>{{cite journal |last1=Wolfe |first1=Marlene |last2=Kaur |first2=Mehar |last3=Yates |first3=Travis |last4=Woodin |first4=Mark |last5=Lantagne |first5=Daniele |title=A Systematic Review and Meta-Analysis of the Association between Water, Sanitation, and Hygiene Exposures and Cholera in Case–Control Studies |journal=The American Journal of Tropical Medicine and Hygiene |date=2 August 2018 |volume=99 |issue=2 |pages=534–545 |doi=10.4269/ajtmh.17-0897 |pmid=29968551 |pmc=6090371 }}</ref>

The cholera toxin (CTX or CT) is an [[Chemistry:Oligomer|oligomer]]ic complex made up of six [[Biology:Protein subunit|protein subunit]]s: a single copy of the A subunit (part A), and five copies of the B subunit (part B), connected by a disulfide bond. The five B subunits form a five-membered ring that binds to [[Chemistry:GM1|GM1]] [[Biology:Ganglioside|ganglioside]]s on the surface of the intestinal epithelium cells. The A1 portion of the A subunit is an enzyme that [[Biology:ADP-ribosylation|ADP-ribosylates]] [[Biology:G protein|G protein]]s, while the A2 chain fits into the central pore of the B subunit ring. Upon binding, the complex is taken into the cell via receptor-mediated [[Biology:Endocytosis|endocytosis]]. Once inside the cell, the disulfide bond is reduced, and the A1 subunit is freed to bind with a human partner protein called ADP-ribosylation factor 6 (Arf6).<ref name=O>{{cite journal | vauthors = O'Neal CJ, Jobling MG, Holmes RK, Hol WG | title = Structural basis for the activation of cholera toxin by human ARF6-GTP | journal = Science | volume = 309 | issue = 5737 | pages = 1093–6 | date = August 2005 | pmid = 16099990 | doi = 10.1126/science.1113398 | s2cid = 8669389 | bibcode = 2005Sci...309.1093O }}</ref> Binding exposes its active site, allowing it to permanently ribosylate the [[Biology:Gs alpha subunit|Gs alpha subunit]] of the [[Biology:Heterotrimeric G protein|heterotrimeric G protein]]. This results in constitutive [[Chemistry:Cyclic adenosine monophosphate|cAMP]] production, which in turn leads to the secretion of water, sodium, potassium, and bicarbonate into the lumen of the small intestine and rapid dehydration. The gene encoding the cholera toxin was introduced into ''V. cholerae'' by [[Biology:Horizontal gene transfer|horizontal gene transfer]]. Virulent strains of ''V. cholerae'' carry a variant of a [[Biology:Temperateness (virology)|temperate]] [[Biology:Bacteriophage|bacteriophage]] called CTXφ.

Microbiologists have studied the [[Biology:Gene expression|genetic mechanisms]] by which the ''V. cholerae'' bacteria turn off the production of some proteins and turn on the production of other proteins as they respond to the series of chemical environments they encounter, passing through the stomach, through the mucous layer of the small intestine, and on to the intestinal wall.<ref name="DiRita">{{cite journal | vauthors = DiRita VJ, Parsot C, Jander G, Mekalanos JJ | title = Regulatory cascade controls virulence in Vibrio cholerae | journal = Proceedings of the National Academy of Sciences of the United States of America | volume = 88 | issue = 12 | pages = 5403–7 | date = June 1991 | pmid = 2052618 | pmc = 51881 | doi = 10.1073/pnas.88.12.5403 | bibcode = 1991PNAS...88.5403D | doi-access = free }}</ref> Of particular interest have been the genetic mechanisms by which cholera bacteria turn on the protein production of the toxins that interact with host cell mechanisms to pump [[Chemistry:Chloride|chloride]] ions into the small intestine, creating an ionic pressure which prevents sodium ions from entering the cell. The chloride and sodium ions create a salt-water environment in the small intestines, which through osmosis can pull up to six liters of water per day through the intestinal cells, creating the massive amounts of diarrhea. The host can become rapidly dehydrated unless treated properly.<ref name="who.int">"Cholera Fact Sheet", World Health Organization. [https://www.who.int/mediacentre/factsheets/fs107/en/index.html who.int] {{webarchive|url=https://web.archive.org/web/20120505185900/http://www.who.int/mediacentre/factsheets/fs107/en/index.html |date=2012-05-05 }}. Retrieved November 5, 2013.</ref>

By inserting separate, successive sections of ''V. cholerae'' DNA into the DNA of other bacteria, such as ''[[Biology:Escherichia coli|E. coli]]'' that would not naturally produce the protein toxins, researchers have investigated the mechanisms by which ''V. cholerae'' responds to the changing chemical environments of the stomach, mucous layers, and intestinal wall. Researchers have discovered a complex cascade of regulatory proteins controls expression of ''V. cholerae'' [[Biology:Virulence|virulence]] determinants.<ref>{{cite journal |last1=Peterson |first1=Kenneth M |last2=Gellings |first2=Patrick S |title=Multiple intraintestinal signals coordinate the regulation of Vibrio cholerae virulence determinants |journal=Pathogens and Disease |date=1 February 2018 |volume=76 |issue=1 |doi=10.1093/femspd/ftx126 |pmid=29315383 |doi-access=free }}</ref> In responding to the chemical environment at the intestinal wall, the ''V. cholerae'' bacteria produce the TcpP/TcpH proteins, which, together with the ToxR/ToxS proteins, activate the expression of the ToxT regulatory protein. ToxT then directly activates expression of [[Biology:Virulence|virulence]] genes that produce the toxins, causing diarrhea in the infected person and allowing the bacteria to colonize the intestine.<ref name="DiRita" /> Current{{when|date=August 2017}} research aims at discovering "the signal that makes the cholera bacteria stop swimming and start to colonize (that is, adhere to the cells of) the small intestine."<ref name="DiRita" />

=== Genetic structure ===
{{Main|Biology:Vibrio cholerae}}
[[Biology:Amplified fragment length polymorphism|Amplified fragment length polymorphism]] [[Biology:DNA profiling|fingerprinting]] of the pandemic isolates of ''V. cholerae'' has revealed variation in the genetic structure. Two [[Biology:Gene cluster|clusters]] have been identified: Cluster I and Cluster II. For the most part, Cluster I consists of strains from the 1960s and 1970s, while Cluster II largely contains strains from the 1980s and 1990s, based on the change in the clone structure. This grouping of strains is best seen in the strains from the African continent.<ref>{{Unreliable medical source|date=December 2013}} {{cite journal | vauthors = Lan R, Reeves PR | title = Pandemic spread of cholera: genetic diversity and relationships within the seventh pandemic clone of Vibrio cholerae determined by amplified fragment length polymorphism | journal = Journal of Clinical Microbiology | volume = 40 | issue = 1 | pages = 172–81 | date = January 2002 | pmid = 11773113 | pmc = 120103 | doi = 10.1128/JCM.40.1.172-181.2002 }}</ref>

=== Antibiotic resistance ===
In many areas of the world, antibiotic resistance is increasing within cholera bacteria. In Bangladesh, for example, most cases are resistant to [[Chemistry:Tetracycline|tetracycline]], trimethoprim-sulfamethoxazole, and [[Chemistry:Erythromycin|erythromycin]].<ref name="NEJM2006" /> Rapid diagnostic [[Biology:Assay|assay]] methods are available for the identification of [[Biology:Multiple drug resistance|multi-drug resistant]] cases.<ref name="Mackay">{{cite book|title=Real-Time PCR in microbiology: From diagnosis to characterization|publisher=Caister Academic Press|year=2007|isbn=978-1-904455-18-9|editor=Mackay IM}}</ref> New generation antimicrobials have been discovered which are effective against cholera bacteria in ''in vitro'' studies.<ref name="Ramamurthy">{{cite book |title=Vibrio cholerae: Genomics and molecular biology |publisher=Caister Academic Press |year=2008 |isbn=978-1-904455-33-2 |chapter=Antibiotic resistance in ''Vibrio cholerae'' |author=Ramamurthy T |chapter-url=https://www.caister.com/hsp/abstracts/vib/12.html |page=195 }}</ref>

== Diagnosis ==
A rapid [[Engineering:Dipstick|dipstick]] test is available to determine the presence of ''V. cholerae''.<ref name="NEJM2006" /> In those samples that test positive, further testing should be done to determine antibiotic resistance.<ref name="NEJM2006" /> In [[Medicine:Epidemic|epidemic]] situations, a clinical diagnosis may be made by taking a [[Medicine:Medical history|patient history]] and doing a brief examination. Treatment via hydration and over-the-counter hydration solutions can be started without or before confirmation by laboratory analysis, especially where cholera is a common problem.<ref>{{Cite web |title=Cholera - Diagnosis and treatment - Mayo Clinic |url=https://www.mayoclinic.org/diseases-conditions/cholera/diagnosis-treatment/drc-20355293 |access-date=2022-09-04 |website=www.mayoclinic.org}}</ref>

Stool and swab samples collected in the acute stage of the disease, before antibiotics have been administered, are the most useful specimens for laboratory diagnosis. If an epidemic of cholera is suspected, the most common causative agent is ''V. cholerae'' O1. If ''V. cholerae'' [[Biology:Serotype|serogroup]] O1 is not isolated, the laboratory should test for ''V. cholerae'' O139. However, if neither of these organisms is isolated, it is necessary to send stool specimens to a reference laboratory.{{citation needed|date=August 2020}}

Infection with ''V. cholerae'' O139 should be reported and handled in the same manner as that caused by ''V. cholerae'' O1. The associated diarrheal illness should be referred to as cholera and must be reported in the United States.<ref name="CDC_Diag">{{cite web|url=https://www.cdc.gov/cholera/pdf/Laboratory-Methods-for-the-Diagnosis-of-Epidemic-Dysentery-and-Cholera.pdf|title=Laboratory Methods for the Diagnosis of Epidemic Dysentery and Cholera|year=1999|publisher=Centers for Disease Control and Prevention|access-date=2017-06-30|url-status=live|archive-url=https://web.archive.org/web/20170623024004/https://www.cdc.gov/cholera/pdf/laboratory-methods-for-the-diagnosis-of-epidemic-dysentery-and-cholera.pdf|archive-date=2017-06-23}}</ref>

== Prevention ==
[[File:It doesn't hurt, but it tickles. A U.S. Navy hospital corpsman, member of a USAID military health team, inoculates a flo - NARA - 541855.jpg|thumb|upright=1.3|Preventive inoculation against cholera in 1966]]
The [[Organization:World Health Organization|World Health Organization]] (WHO) recommends focusing on prevention, preparedness, and response to combat the spread of cholera.<ref name="who.int" /> They also stress the importance of an effective surveillance system.<ref name="who.int" /> Governments can play a role in all of these areas.

=== Water, sanitation and hygiene ===
Although cholera may be life-threatening, prevention of the disease is normally straightforward if proper [[Engineering:Sanitation|sanitation]] practices are followed. In developed countries, due to their nearly universal advanced [[Earth:Water treatment|water treatment]] and sanitation practices, cholera is rare. For example, the last major outbreak of cholera in the United States occurred in 1910–1911.<ref name="moltke1">{{cite news |title=CHOLERA KILLS BOY; EIGHTH DEATH HERE; All Other Suspected Cases Now in Quarantine and Show No Alarming Symptoms. |url=https://www.nytimes.com/1911/07/18/archives/cholera-kills-boy-eighth-death-here-all-other-suspected-cases-now.html |work=The New York Times |date=18 July 1911 }}</ref><ref name="moltke2">{{cite news |title=More Cholera in Port |url=https://pqasb.pqarchiver.com/washingtonpost_historical/access/250061412.html?dids=250061412:250061412&FMT=ABS&FMTS=ABS:FT&date=OCT+10%2C+1910&author=&pub=The+Washington+Post&desc=MORE+CHOLERA+IN+PORT&pqatl=google |quote=A case of cholera developed today in the steerage of the Hamburg-American liner Moltke, which has been detained at quarantine as a possible cholera carrier since Monday last. Dr. A.H. Doty, health officer of the port, reported the case tonight with the additional information that another cholera patient from the Moltke is under treatment at Swinburne Island. |newspaper={{wipe|The Washington Post}} |date=October 10, 1910 |access-date=2008-12-11 |url-status=live |archive-url=https://web.archive.org/web/20081216072507/http://pqasb.pqarchiver.com/washingtonpost_historical/access/250061412.html?dids=250061412%3A250061412&FMT=ABS&FMTS=ABS%3AFT&date=OCT+10%2C+1910&author=&pub=The+Washington+Post&desc=MORE+CHOLERA+IN+PORT&pqatl=google |archive-date=December 16, 2008 }}</ref> Cholera is mainly a risk in [[Finance:Developing country|developing countries]] in those areas where access to [[Engineering:WASH|WASH (water, sanitation and hygiene)]] infrastructure is still inadequate.

Effective sanitation practices, if instituted and adhered to in time, are usually sufficient to stop an epidemic. There are several points along the cholera transmission path at which its spread may be halted:<ref>{{Cite web|title=Cholera|url=https://www.who.int/news-room/fact-sheets/detail/cholera|access-date=2020-08-20|website=www.who.int|language=en}}</ref>
* Sterilization: Proper disposal and treatment of all materials that may have come into contact with the feces of other people with cholera (e.g., clothing, bedding, etc.) are essential. These should be sanitized by washing in hot water, using [[Chemistry:Chlorine|chlorine]] [[Chemistry:Bleach|bleach]] if possible. Hands that touch cholera patients or their clothing, bedding, etc., should be thoroughly cleaned and disinfected with chlorinated water or other effective antimicrobial agents.
* [[Earth:Sewage|Sewage]] and [[Engineering:Fecal sludge management|fecal sludge management]]: In cholera-affected areas, sewage and fecal sludge need to be treated and managed carefully in order to stop the spread of this disease via human excreta. Provision of [[Engineering:Sanitation|sanitation]] and hygiene is an important preventative measure.<ref name="who.int" /> Open defecation, release of untreated sewage, or dumping of fecal sludge from [[Engineering:Pit latrine|pit latrine]]s or [[Engineering:Septic tank|septic tank]]s into the environment need to be prevented.<ref>{{Cite book|url=https://books.google.com/books?id=AGQVBeNM_80C&pg=PA5|title=Urban Water Security: Managing Risks: UNESCO-IHP|last1=Cisneros|first1=Blanca Jimenez|last2=Rose|first2=Joan B. | name-list-style = vanc |date=2009-03-24|publisher=CRC Press|isbn=978-0-203-88162-0|language=en}}</ref> In many cholera affected zones, there is a low degree of [[Earth:Sewage treatment|sewage treatment]].<ref>{{Cite book|url=https://books.google.com/books?id=rd3zCAAAQBAJ&pg=GBS.PA24|title=Cholera and the Ecology of Vibrio cholerae| vauthors = Drasar BS, Forrest DB  |date=2012-12-06|publisher=Springer Science & Business Media|isbn=978-94-009-1515-2|page=24}}</ref><ref>{{Cite book|url=https://books.google.com/books?id=dAT9CgAAQBAJ&pg=PA219|title=A Companion to the Anthropology of Environmental Health|last=Singer|first=Merrill  | name-list-style = vanc |date=2016-05-31|publisher=John Wiley & Sons|isbn=978-1-118-78699-4|page=219}}</ref> Therefore, the implementation of dry toilets that do not contribute to [[Earth:Water pollution|water pollution]], as they do not flush with water, may be an interesting alternative to flush toilets.<ref>{{cite news |last1=Gili |first1=Enrique |date=9 June 2015 |title=Starting a poop to compost movement |url=https://www.dw.com/en/global-ideas-haiti-poop-compost-toilets/a-18504469 |work=Deutsche Welle }}</ref>
* Sources: Warnings about possible cholera contamination should be posted around contaminated water sources with directions on how to decontaminate the water (boiling, chlorination etc.) for possible use.
* [[Earth:Water purification|Water purification]]: All water used for drinking, washing, or cooking should be sterilized by either boiling, [[Chemistry:Water chlorination|chlorination]], ozone water treatment, ultraviolet light sterilization (e.g., by [[Chemistry:Solar water disinfection|solar water disinfection]]), or antimicrobial filtration in any area where cholera may be present. Chlorination and boiling are often the least expensive and most effective means of halting transmission. [[Chemistry:Cloth filter|Cloth filter]]s or sari filtration, though very basic, have significantly reduced the occurrence of cholera when used in poor villages in Bangladesh that rely on untreated surface water. Better antimicrobial filters, like those present in advanced individual water treatment hiking kits, are most effective. Public health education and adherence to appropriate sanitation practices are of primary importance to help prevent and control transmission of cholera and other diseases.

Handwashing with soap or ash after using a [[Engineering:Toilet|toilet]] and before handling food or eating is also recommended for cholera prevention by WHO Africa.<ref>{{cite web |title=Cholera and food safety |url=http://who.insomnation.com/sites/default/files/pdf/fan_cholera%20fact%20sheet7.pdf |publisher=[[Organization:World Health Organization|World Health Organization]] |access-date=2017-08-20 |url-status=dead |archive-url=https://web.archive.org/web/20170821044840/http://who.insomnation.com/sites/default/files/pdf/fan_cholera%20fact%20sheet7.pdf |archive-date=2017-08-21 }}</ref>

<gallery class="center" widths="225px" heights="200px">
File:Unsafe disposal of faecal sludge or sewage in Haiti (6458176073).jpg|Dumping of [[Earth:Sewage|sewage]] or [[Engineering:Fecal sludge management|fecal sludge]] from a UN camp into a lake in the surroundings of [[Place:Port-au-Prince|Port-au-Prince]] is thought to have contributed to the spread of cholera after the Haiti earthquake in 2010, killing thousands.
File:A SOIL EkoLakay toilet customer. (15921409131).jpg|Example of a [[Engineering:Urine-diverting dry toilet|urine-diverting dry toilet]] in a cholera-affected area in Haiti.  This type of toilet stops transmission of disease via the [[Biology:Fecal–oral route|fecal-oral route]] due to [[Earth:Water pollution|water pollution]].
File:Cholera hospital in Dhaka.jpg|[[Organization:International Centre for Diarrhoeal Disease Research, Bangladesh|Cholera hospital]] in [[Place:Dhaka|Dhaka]], showing typical "cholera beds".
</gallery>

=== Surveillance ===
[[File:Using Precipitation Data to Assess Risk of Cholera Outbreaks.webm|thumb|upright=1.3|A modelling approach using satellite data can enhance our ability to develop cholera risk maps in several regions of the globe.]]
Surveillance and prompt reporting allow for containing cholera epidemics rapidly. Cholera exists as a seasonal disease in many endemic countries, occurring annually mostly during rainy seasons. Surveillance systems can provide early alerts to outbreaks, therefore leading to coordinated response and assist in preparation of preparedness plans. Efficient surveillance systems can also improve the risk assessment for potential cholera outbreaks. Understanding the seasonality and location of outbreaks provides guidance for improving cholera control activities for the most vulnerable.<ref>{{cite web |url=https://www.who.int/topics/cholera/control/en/index.html |title=Cholera: prevention and control |publisher=WHO |work=Health topics |year=2008 |access-date=2008-12-08 |url-status=dead |archive-url=https://web.archive.org/web/20081214042133/http://www.who.int/topics/cholera/control/en/index.html |archive-date=2008-12-14 }}</ref> For prevention to be effective, it is important that cases be reported to national health authorities.<ref name=Lancet2004 />

=== Vaccination ===
{{Main|Medicine:Cholera vaccine}}
[[File:Euvichol-plus.jpg|thumb|Euvichol-plus oral vaccine for cholera]]
Spanish physician Jaume Ferran i Clua developed the first successful cholera inoculation in 1885, the first to immunize humans against a bacterial disease.<ref>{{Cite web|url=http://www.historyofvaccines.org/content/timelines/others|archiveurl=https://web.archive.org/web/20150211100824/http://www.historyofvaccines.org/content/timelines/others|url-status=unfit|title=Others — Timelines — History of Vaccines|archivedate=February 11, 2015}}</ref> His vaccine and inoculation was rather controversial and was rejected by his peers and several investigation commissions but it ended up demonstrating its effectiveness and being recognized for it: out of the 30 thousand people he vaccinated only 54 died.<ref name=":0">{{cite journal |last1=Bornside |first1=George H. |title=Waldemar Haffkine's Cholera Vaccines and the Ferran-Haffkine Priority Dispute |journal=Journal of the History of Medicine and Allied Sciences |date=1982 |volume=XXXVII |issue=4 |pages=399–422 |doi=10.1093/jhmas/xxxvii.4.399 |pmid=6759570 }}</ref><ref name=":1">{{cite journal |last1=Bornside |first1=George H. |title=Jaime Ferran and Preventive Inoculation Against Cholera |journal=Bulletin of the History of Medicine |date=1981 |volume=55 |issue=4 |pages=516–532 |jstor=44441415 |pmid=7039738 }}</ref><ref name=":2">{{cite journal |last1=Hawgood |first1=Barbara J |title=Waldemar Mordecai Haffkine, CIE (1860–1930): prophylactic vaccination against cholera and bubonic plague in British India |journal=Journal of Medical Biography |date=February 2007 |volume=15 |issue=1 |pages=9–19 |doi=10.1258/j.jmb.2007.05-59 |pmid=17356724 |s2cid=42075270 }}</ref><ref>{{Cite journal |last1=Lopez |first1=Anna Lena |last2=Gonzales |first2=Maria Liza Antoinette |last3=Aldaba |first3=Josephine G. |last4=Nair |first4=G. Balakrish |date=September 2014 |title=Killed oral cholera vaccines: history, development and implementation challenges |journal=Therapeutic Advances in Vaccines |volume=2 |issue=5 |pages=123–136 |doi=10.1177/2051013614537819 |issn=2051-0136 |pmc=4144262 |pmid=25177492}}</ref> Russian-Jewish bacteriologist [[Biography:Waldemar Haffkine|Waldemar Haffkine]] also developed a human cholera vaccine in July 1892.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref>[http://www.haffkineinstitute.org/waldemar.htm haffkineinstitute.org] {{webarchive|url=https://web.archive.org/web/20150924024552/http://www.haffkineinstitute.org/waldemar.htm|date=2015-09-24}}</ref> He conducted a massive inoculation program in British India.<ref name=":2" /><ref>{{Cite news|date=2020-12-11|title=Waldemar Haffkine: The vaccine pioneer the world forgot|language=en-GB|work=BBC News|url=https://www.bbc.com/news/world-asia-india-55050012|access-date=2021-01-20}}</ref>

Persons who survive an episode of cholera have long-lasting immunity for at least 3 years (the period tested.)<ref name="immunity"/> A number of safe and effective oral vaccines for cholera are available.<ref name="pmid21412922">{{cite journal | vauthors = Sinclair D, Abba K, Zaman K, Qadri F, Graves PM | title = Oral vaccines for preventing cholera | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD008603 | date = March 2011 | volume = 2011 | pmid = 21412922 | pmc = 6532691 | doi = 10.1002/14651858.CD008603.pub2 | editor = Sinclair D }}</ref>  The World Health Organization (WHO) has three prequalified oral cholera vaccines (OCVs): Dukoral, Sanchol, and Euvichol. Dukoral, an orally administered, inactivated [[Medicine:Whole-cell vaccine|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.<ref name="pmid21412922" />  It is available in over 60 countries. However, it is not currently{{when|date=August 2017}} recommended by the Centers for Disease Control and Prevention (CDC) for most people traveling from the United States to endemic countries.<ref name="CDC_Vacc">{{cite web| title=Is a vaccine available to prevent cholera?| work=CDC disease info: Cholera| url=https://www.cdc.gov/cholera/general/#vaccine| date=2010-10-22| access-date=2010-10-24| url-status=live| archive-url=https://web.archive.org/web/20101026085158/http://www.cdc.gov/cholera/general/#vaccine| archive-date=2010-10-26}}</ref> The vaccine that the [[Organization:Food and Drug Administration|US Food and Drug Administration]] (FDA) recommends, Vaxchora, is an [[Medicine:Cholera vaccine#Oral|oral attenuated live vaccine]],  that is effective for adults aged 18–64 as a single dose.<ref>{{Cite web|url=http://www.immunize.org/fda/|archiveurl=https://web.archive.org/web/20170415125256/http://www.immunize.org/fda/|url-status=dead|title=FDA Product Approval: View All|archivedate=April 15, 2017}}</ref>

One injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than five years old.<ref>{{cite journal | vauthors = Graves PM, Deeks JJ, Demicheli V, Jefferson T | title = Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD000974 | date = August 2010 | volume = 2019 | pmid = 20687062 | pmc = 6532721 | doi = 10.1002/14651858.CD000974.pub2 | editor = Graves PM }}</ref> However, {{as of|2010|lc=y}}, it has limited availability.<ref name=WHO2010 /> Work is under way to investigate the role of mass vaccination.<ref>{{cite web |url=https://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 |access-date=2010-02-01 |url-status=dead |archive-url=https://web.archive.org/web/20100216224558/http://who.int/topics/cholera/vaccines/en/index.html |archive-date=2010-02-16 }}</ref> The WHO recommends immunization of high-risk groups, such as children and people with [[Biology:HIV|HIV]], in countries where this disease is [[Biology:Endemism|endemic]].<ref name=WHO2010 />  If people are immunized broadly, [[Medicine:Herd immunity|herd immunity]] results, with a decrease in the amount of contamination in the environment.<ref name=NEJM2006 />

WHO recommends that oral cholera vaccination be considered in areas where the disease is endemic (with seasonal peaks), as part of the response to outbreaks, or in a humanitarian crisis during which the risk of cholera is high.<ref>{{cite journal |title=News from the World Health Organization: Epidemiological Methods for Environmental Health Initiatives in WHO |journal=International Journal of Epidemiology |date=1993 |volume=22 |issue=5 |pages=961–962 |doi=10.1093/ije/22.5.961 }}</ref> Oral Cholera Vaccine (OCV) has been recognized as an adjunct tool for prevention and control of cholera. The World Health Organization (WHO) has prequalified three bivalent cholera vaccines—Dukoral (SBL Vaccines), containing a non-toxic B-subunit of cholera toxin and providing protection against V. cholerae O1; and two vaccines developed using the same transfer of technology—ShanChol (Shantha Biotec) and Euvichol (EuBiologics Co.), which have bivalent O1 and O139 oral killed cholera vaccines.<ref>{{cite journal|vauthors=Ryan ET|date=January 2011|title=The cholera pandemic, still with us after half a century: time to rethink|journal=PLOS Neglected Tropical Diseases|volume=5|issue=1|pages=e1003|doi=10.1371/journal.pntd.0001003|pmc=3026764|pmid=21283611 |doi-access=free }}</ref> Oral cholera vaccination could be deployed in a diverse range of situations from cholera-endemic areas and locations of humanitarian crises, but no clear consensus exists.<ref>{{cite journal|display-authors=6|vauthors=Deen J, von Seidlein L, Luquero FJ, Troeger C, Reyburn R, Lopez AL, Debes A, Sack DA|date=January 2016|title=The scenario approach for countries considering the addition of oral cholera vaccination in cholera preparedness and control plans|journal=The Lancet. Infectious Diseases|volume=16|issue=1|pages=125–129|doi=10.1016/S1473-3099(15)00298-4|pmid=26494426|doi-access=}}</ref>

=== Sari filtration ===
{{Main|Chemistry:Cloth filter}} 
[[Image:Washing Utensils And Vegetables.png|Women at a village pond in Matlab, Bangladesh washing utensils and vegetables. The woman on the right is putting a sari filter onto a water-collecting pot (or kalash) to filter water for drinking.|thumb|240px]]

Developed for use in Bangladesh, the "sari filter" is a simple and cost-effective [[Engineering:Appropriate technology|appropriate technology]] method for reducing the contamination of drinking water. Used sari cloth is preferable but other types of used cloth can be used with some effect, though the effectiveness will vary significantly. Used cloth is more effective than new cloth, as the repeated washing reduces the space between the fibers. Water collected in this way has a greatly reduced [[Biology:Pathogen|pathogen]] count—though it will not necessarily be perfectly safe, it is an improvement for poor people with limited options.<ref name=Ram2010>{{cite book|author=Ramamurthy T|title=Epidemiological and Molecular Aspects on Cholera|year=2010|publisher=Springer|isbn=978-1-60327-265-0|page=330|url=https://books.google.com/books?id=X1DI0Easu2YC&pg=PA330|url-status=live|archive-url=https://web.archive.org/web/20151107134836/https://books.google.com/books?id=X1DI0Easu2YC&pg=PA330|archive-date=2015-11-07}}</ref> In Bangladesh this practice was found to decrease rates of cholera by nearly half.<ref name=Merr2010>{{cite book|author=Merrill RM|title=Introduction to epidemiology.|year=2010|publisher=Jones and Bartlett Publishers|location=Sudbury, MA|isbn=978-0-7637-6622-1|page=43|url=https://books.google.com/books?id=RMDBh6gw1_UC&pg=PA43|edition=5th|url-status=live|archive-url=https://web.archive.org/web/20151106194307/https://books.google.com/books?id=RMDBh6gw1_UC&pg=PA43|archive-date=2015-11-06}}</ref> It involves folding a ''sari'' four to eight times.<ref name=Ram2010 /> Between uses the cloth should be rinsed in clean water and dried in the sun to kill any bacteria on it.<ref>{{cite book|author=Starr C|title=Biology: Today and Tomorrow with Physiology|year=2007|publisher=Cengage Learning|isbn=978-1-111-79701-0|page=563|url=https://books.google.com/books?id=-bsFAAAAQBAJ&pg=PA563|edition=2|url-status=live|archive-url=https://web.archive.org/web/20151107022134/https://books.google.com/books?id=-bsFAAAAQBAJ&pg=PA563|archive-date=2015-11-07}}</ref> A [[Chemistry:Nylon|nylon]] cloth appears to work as well but is not as affordable.<ref name=Merr2010 />

== Treatment ==
[[File:Cholera rehydration nurses.jpg|thumb|upright=1.3|Cholera patient being treated by oral rehydration therapy in 1992]]
Continued eating speeds the recovery of normal intestinal function. The WHO recommends this generally for cases of diarrhea no matter what the underlying cause.<ref name=WHOTreatmentOfDiarrhoea2005 /> A CDC training manual specifically for cholera states: "Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."<ref name=CDCCommunityHealthWorkerTrainingManual>{{cite web|url=https://www.cdc.gov/cholera/pdf/chw-trainingmaterials-haiti-specific-508c.pdf|title=Community Health Worker Training Materials for Cholera Prevention and Control|publisher=Centers for Disease Control and Prevention|url-status=live|archive-url=https://web.archive.org/web/20170702064520/https://www.cdc.gov/cholera/pdf/chw-trainingmaterials-haiti-specific-508c.pdf|archive-date=2017-07-02}}</ref>

=== Fluids ===
The most common error in caring for patients with cholera is to underestimate the speed
and volume of fluids required.<ref>{{Cite web|url=http://globalhealthcenter.umn.edu/documents/Cholera-Lancet-July2012.pdf|archiveurl=https://web.archive.org/web/20131203010620/http://globalhealthcenter.umn.edu/documents/Cholera-Lancet-July2012.pdf|url-status=dead|title=globalhealthcenter.umn.edu|archivedate=December 3, 2013}}</ref> In most cases, cholera can be successfully treated with [[Medicine:Oral rehydration therapy|oral rehydration therapy]] (ORT), which is highly effective, safe, and simple to administer.<ref name=NEJM2006 /> Rice-based solutions are preferred to glucose-based ones due to greater efficiency.<ref name=NEJM2006 /> In severe cases with significant dehydration, intravenous rehydration may be necessary. Ringer's lactate is the preferred solution, often with added potassium.<ref name=Lancet2004 /><ref name=WHOTreatmentOfDiarrhoea2005>{{cite book |title=The treatment of diarrhoea: a manual for physicians and other senior health workers |date=2005 |publisher=World Health Organization |pages=10, 16–17 |isbn=978-92-4-159318-2 |hdl=10665/43209 |hdl-access=free }}</ref> Large volumes and continued replacement until diarrhea has subsided may be needed.<ref name=Lancet2004 /> Ten percent of a person's body weight in fluid may need to be given in the first two to four hours.<ref name=Lancet2004 /> This method was first tried on a mass scale during the Bangladesh Liberation War, and was found to have much success.<ref>[https://foreignpolicy.com/articles/2011/03/21/the_civil_war_that_killed_cholera The Civil War That Killed Cholera] {{webarchive|url=https://web.archive.org/web/20131220165056/http://www.foreignpolicy.com/articles/2011/03/21/the_civil_war_that_killed_cholera |date=2013-12-20 }}, foreignpolicy.com.</ref>  Despite widespread beliefs, fruit juices and commercial fizzy drinks like cola are not ideal for rehydration of people with serious infections of the intestines, and their excessive sugar content may even harm water uptake.<ref>{{cite news |title=Sugary drinks 'worsen vomit bug' |url=http://news.bbc.co.uk/2/hi/health/8010346.stm |work=BBC News |date=22 April 2009 }}</ref>

If commercially produced oral rehydration solutions are too expensive or difficult to obtain, solutions can be made. One such recipe calls for 1 liter of boiled water, 1/2 teaspoon of salt, 6 teaspoons of sugar, and added mashed banana for potassium and to improve taste.<ref>{{cite web|url=http://rehydrate.org/solutions/homemade.htm|title=Oral Rehydration Solutions: Made at Home|year=2010|access-date=2010-10-29|publisher=The Mother and Child Health and Education Trust|url-status=dead|archive-url=https://web.archive.org/web/20101124130823/http://rehydrate.org/solutions/homemade.htm|archive-date=2010-11-24}}</ref>

=== Electrolytes ===
As there frequently is initially acidosis, the [[Chemistry:Potassium|potassium]] level may be normal, even though large losses have occurred.<ref name=Lancet2004 /> As the dehydration is corrected, potassium levels may decrease rapidly, and thus need to be replaced.<ref name=Lancet2004 />  This may be done by consuming foods high in potassium, like bananas or coconut water.<ref name=choleraoutbreaksteps />

=== Antibiotics ===
[[Chemistry:Antibiotic|Antibiotic]] treatments for one to three days shorten the course of the disease and reduce the severity of the symptoms.<ref name=Lancet2004 /> Use of antibiotics also reduces fluid requirements.<ref>{{cite report|date=November 28, 2011|title=Cholera Treatment|url=https://www.cdc.gov/cholera/treatment/index.html|publisher=Centers for Disease Control and Prevention (CDC)|url-status=live|archive-url=https://web.archive.org/web/20150311042338/http://www.cdc.gov/cholera/treatment/index.html|archive-date=March 11, 2015}}</ref> People will recover without them, however, if sufficient hydration is maintained.<ref name=NEJM2006 /> The WHO only recommends antibiotics in those with severe dehydration.<ref name=choleraoutbreaksteps>{{cite web|title=First steps for managing an outbreak of acute diarrhea|url=https://www.who.int/topics/cholera/publications/en/first_steps.pdf|publisher=World Health Organization Global Task Force on Cholera Control|access-date=November 23, 2013|url-status=live|archive-url=https://web.archive.org/web/20140805150434/http://www.who.int/topics/cholera/publications/en/first_steps.pdf|archive-date=August 5, 2014}}</ref>

[[Chemistry:Doxycycline|Doxycycline]] is typically used first line, although some [[Biology:Strain|strains]] of ''V. cholerae'' have shown resistance.<ref name=Lancet2004 /> Testing for resistance during an outbreak can help determine appropriate future choices.<ref name=Lancet2004 /> Other antibiotics proven to be effective include cotrimoxazole, [[Chemistry:Erythromycin|erythromycin]], [[Chemistry:Tetracycline|tetracycline]], [[Chemistry:Chloramphenicol|chloramphenicol]], and [[Biology:Furazolidone|furazolidone]].<ref>{{cite web |archive-url=https://web.archive.org/web/20121106021041/http://sprojects.mmi.mcgill.ca/tropmed/disease/chol/treatment.htm|archive-date=6 November 2012|url=http://sprojects.mmi.mcgill.ca/tropmed/disease/chol/treatment.htm |title=Cholera treatment|publisher=Molson Medical Informatics |year=2007 |access-date=2008-01-03}}</ref> Fluoroquinolones, such as [[Chemistry:Ciprofloxacin|ciprofloxacin]], also may be used, but resistance has been reported.<ref>{{cite journal | vauthors = Krishna BV, Patil AB, Chandrasekhar MR | title = Fluoroquinolone-resistant Vibrio cholerae isolated during a cholera outbreak in India | journal = Transactions of the Royal Society of Tropical Medicine and Hygiene | volume = 100 | issue = 3 | pages = 224–6 | date = March 2006 | pmid = 16246383 | doi = 10.1016/j.trstmh.2005.07.007 }}</ref>

Antibiotics improve outcomes in those who are both severely and not severely dehydrated.<ref name="Lei2014">{{cite journal | vauthors = Leibovici-Weissman Y, Neuberger A, Bitterman R, Sinclair D, Salam MA, Paul M | title = Antimicrobial drugs for treating cholera | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD008625 | date = June 2014 | volume = 2014 | pmid = 24944120 | pmc = 4468928 | doi = 10.1002/14651858.CD008625.pub2 }}</ref> [[Chemistry:Azithromycin|Azithromycin]] and [[Chemistry:Tetracycline|tetracycline]] may work better than [[Chemistry:Doxycycline|doxycycline]] or [[Chemistry:Ciprofloxacin|ciprofloxacin]].<ref name="Lei2014" />

=== Zinc supplementation ===
In Bangladesh [[Chemistry:Zinc|zinc]] supplementation reduced the duration and severity of diarrhea in children with cholera when given with antibiotics and rehydration therapy as needed. It reduced the length of disease by eight hours and the amount of diarrhea stool by 10%.<ref name=CDC2013>{{cite report|date=November 28, 2011|title=Cholera-Zinc Treatment|url=https://www.cdc.gov/cholera/treatment/zinc-treatment.html|publisher=Centers for Disease Control and Prevention (CDC)|url-status=live|archive-url=https://web.archive.org/web/20131203084037/http://www.cdc.gov/cholera/treatment/zinc-treatment.html|archive-date=December 3, 2013}}</ref> Supplementation appears to be also effective in both treating and preventing infectious diarrhea due to other causes among children in the developing world.<ref name=CDC2013 /><ref>{{cite journal | vauthors = Telmesani AM | title = Oral rehydration salts, zinc supplement and rota virus vaccine in the management of childhood acute diarrhea | journal = Journal of Family & Community Medicine | volume = 17 | issue = 2 | pages = 79–82 | date = May 2010 | pmid = 21359029 | pmc = 3045093 | doi = 10.4103/1319-1683.71988 | doi-access = free }}</ref>

== Prognosis ==
If people with cholera are treated quickly and properly, the mortality rate is less than 1%; however, with untreated cholera, the mortality rate rises to 50–60%.<ref name="Lancet2004" /><ref name=textbook>{{cite web|url=http://www.textbookofbacteriology.net/cholera.html|title=''Vibrio cholerae'' and Asiatic Cholera|publisher=Todar's Online Textbook of Bacteriology|author=Todar K|access-date=2010-12-20|url-status=dead|archive-url=https://web.archive.org/web/20101228115128/http://www.textbookofbacteriology.net/cholera.html|archive-date=2010-12-28}}</ref>

For certain genetic strains of cholera, such as the one present during the 2010 epidemic in Haiti and the 2004 outbreak in India, death can occur within two hours of becoming ill.<ref name="Knox2010">{{cite news |last1=Knox |first1=Richard |title=Toward A New Strategy For Fighting Cholera In Haiti |url=https://www.npr.org/sections/health-shots/2010/12/10/131972272/toward-a-new-strategy-for-fighting-cholera-in-haiti |work=NPR |date=10 December 2010 }}</ref>

== Epidemiology ==
Cholera affects an estimated 2.8&nbsp;million people worldwide, and causes approximately 95,000&nbsp;deaths a year (uncertainty range: 21,000–143,000) {{as of|2015|lc=y}}.<ref>{{cite journal |last1=Ali |first1=Mohammad |last2=Nelson |first2=Allyson R. |last3=Lopez |first3=Anna Lena |last4=Sack |first4=David A. |title=Updated Global Burden of Cholera in Endemic Countries |journal=PLOS Neglected Tropical Diseases |date=4 June 2015 |volume=9 |issue=6 |pages=e0003832 |doi=10.1371/journal.pntd.0003832 |pmid=26043000 |pmc=4455997 |doi-access=free }}</ref><ref name=Loz2012>{{cite journal |last1=Lozano |first1=Rafael |last2=Naghavi |first2=Mohsen |last3=Foreman |first3=Kyle |last4=Lim |first4=Stephen |last5=Shibuya |first5=Kenji |last6=Aboyans |first6=Victor |last7=Abraham |first7=Jerry |last8=Adair |first8=Timothy |last9=Aggarwal |first9=Rakesh |last10=Ahn |first10=Stephanie Y |last11=AlMazroa |first11=Mohammad A |last12=Alvarado |first12=Miriam |last13=Anderson |first13=H Ross 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|last188=Zabetian |first188=Azadeh |last189=Zheng |first189=Zhi-Jie |last190=Lopez |first190=Alan D |last191=Murray |first191=Christopher JL |title=Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010 |journal=The Lancet |date=December 2012 |volume=380 |issue=9859 |pages=2095–2128 |doi=10.1016/S0140-6736(12)61728-0 |pmid=23245604 |pmc=10790329 |s2cid=1541253 |hdl=10536/DRO/DU:30050819 |url=https://repozitorij.upr.si/Dokument.php?id=7123&dn= |hdl-access=free }}</ref> This occurs mainly in the developing world.<ref>{{cite journal |last1=Reidl |first1=Joachim |last2=Klose |first2=Karl E. |title=Vibrio cholerae and cholera: out of the water and into the host |journal=FEMS Microbiology Reviews |date=June 2002 |volume=26 |issue=2 |pages=125–139 |doi=10.1111/j.1574-6976.2002.tb00605.x |pmid=12069878 |doi-access=free }}</ref>

In the early 1980s, death rates are believed to have still been higher than three million a year.<ref name=Lancet2004 /> It is difficult to calculate exact numbers of cases, as many go unreported due to concerns that an outbreak may have a negative impact on the tourism of a country.<ref name=NEJM2006>{{cite journal | vauthors = Sack DA, Sack RB, Chaignat CL | title = Getting serious about cholera | journal = The New England Journal of Medicine | volume = 355 | issue = 7 | pages = 649–51 | date = August 2006 | pmid = 16914700 | doi = 10.1056/NEJMp068144 | s2cid = 23145226 }}</ref> As of 2004, cholera remained both [[Medicine:Epidemic|epidemic]] and endemic in many areas of the world.<ref name=Lancet2004 />

Recent major outbreaks are the 2010s Haiti cholera outbreak and the 2016–2022 Yemen cholera outbreak. In October 2016, an outbreak of cholera began in war-ravaged Yemen.<ref>{{cite web|url=https://www.bbc.co.uk/news/world-middle-east-40369804 |title=The horrors of Yemen's spiralling cholera crisis |publisher=BBC |author=Johannes Bruwer |date=25 June 2017}}</ref> WHO called it "the worst cholera outbreak in the world".<ref>{{cite news|last1=Dwyer|first1=Colin | name-list-style = vanc |title=Yemen Now Faces 'The Worst Cholera Outbreak In The World,' U.N. Says|url=https://www.npr.org/sections/thetwo-way/2017/06/24/534236954/yemen-now-faces-the-worst-cholera-outbreak-in-the-world-u-n-says|access-date=25 June 2017|work=National Public Radio}}</ref> In 2019, 93% of the reported 923,037 cholera cases were from Yemen (with 1911 deaths reported).<ref name="who_report2020"/> Between September 2019 and September 2020, a global total of over 450,000 cases and over 900 deaths was reported; however, the accuracy of these numbers suffer from over-reporting from countries that report suspected cases (and not laboratory confirmed cases), as well as under-reporting from countries that do not report official cases (such as Bangladesh, India and Philippines).<ref name="who_report2020"/>

Although much is known about the mechanisms behind the spread of cholera, researchers still do not have a full understanding of what makes cholera outbreaks happen in some places and not others. Lack of treatment of human [[Biology:Feces|feces]] and lack of treatment of drinking water greatly facilitate its spread. Bodies of water have been found to serve as a [[Biology:Natural reservoir|reservoir]] of infection, and seafood shipped long distances can spread the disease.

Cholera had disappeared from the [[Earth:Americas|Americas]] for most of the 20th century, but it reappeared toward the end of that century, beginning with a severe outbreak in Peru.<ref>{{cite journal | vauthors = Blake PA | title = Epidemiology of cholera in the Americas | journal = Gastroenterology Clinics of North America | volume = 22 | issue = 3 | pages = 639–60 | date = September 1993 | doi = 10.1016/S0889-8553(21)00094-7 | pmid = 7691740 }}</ref> This was followed by the 2010s Haiti cholera outbreak<ref name="ecdc_cholera">{{Cite web|url=https://www.ecdc.europa.eu/en/all-topics-z/cholera/surveillance-and-disease-data/cholera-monthly|title=Cholera worldwide overview|date=May 30, 2023|website=www.ecdc.europa.eu}}</ref> and another outbreak of cholera in Haiti amid the 2018–2023 Haitian crisis.<ref>{{cite news |title=Cholera - Haiti |url=https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON427 |access-date=1 February 2023 |work=www.who.int |language=en}}</ref> {{as of|August 2021}} the disease is endemic in Africa and some areas of eastern and western Asia (Bangladesh, India and Yemen).<ref name="ecdc_cholera"/> Cholera is not endemic in Europe; all reported cases had a travel history to endemic areas.<ref name="ecdc_cholera"/>

=== History of outbreaks ===
[[File:Il cholera di Palermo del 1835.jpg|thumb|upright=1.3|Disposal of dead bodies during the cholera epidemic in Palermo in 1835]]
[[File:Africa cholera2008b.jpg|thumb|upright=1.3|Map of the 2008–2009 cholera outbreak in sub-Saharan Africa showing the statistics as of 12 February 2009]]

The word cholera is from {{lang-el|χολέρα}} ''kholera'' from χολή ''kholē'' "bile". Cholera likely has its origins in the [[Earth:Indian subcontinent|Indian subcontinent]] as evidenced by its prevalence in the region for centuries.<ref name=Lancet2004 />

References to cholera appear in the European literature as early as 1642, from the Dutch physician Jakob de Bondt's description in his De Medicina Indorum.<ref>{{Cite web|url=http://www.historyofmedicine.com/author/d/jacob-de-jacobus-bontius-bondt|title=All Entries by BONDT, Jacob de, Jacobus Bontius: HistoryofMedicine.com|website=www.historyofmedicine.com|language=en-us|access-date=2019-07-23}}</ref> (The "Indorum" of the title refers to the East Indies. He also gave first European descriptions of other diseases.) But at the time, the word "cholera" was historically used by European physicians to refer to any gastrointestinal upset resulting in yellow diarrhea. De Bondt thus used a common word already in regular use to describe the new disease. This was a frequent practice of the time. It was not until the 1830s that the name for severe yellow diarrhea changed in English from "cholera" to "cholera morbus" to differentiate it from what was then known as "Asiatic cholera", or that associated with origins in India and the East.

Early outbreaks in the Indian subcontinent are believed to have been the result of crowded, poor living conditions, as well as the presence of pools of still water, both of which provide ideal conditions for cholera to thrive.<ref name=Rosenberg /> The disease first spread by travelers along trade routes (land and sea) to {{wipe|Russia}} in 1817, later to the rest of [[Earth:Europe|Europe]], and from Europe to [[Earth:North America|North America]] and the rest of the world,<ref name=Lancet2004 /> (hence the name "Asiatic cholera"<ref name=textbook/>). Seven cholera pandemics have occurred since the early 19th century; the first one did not reach the Americas. The seventh [[Finance:Pandemic|pandemic]] originated in Indonesia in 1961.<ref>"[http://www.cbc.ca/news/technology/cholera-s-seven-pandemics-1.758504 Cholera's seven pandemics] {{webarchive|url=https://web.archive.org/web/20160302113041/http://www.cbc.ca/news/technology/cholera-s-seven-pandemics-1.758504 |date=2016-03-02 }}". CBC News. October 22, 2010.</ref>

The first cholera pandemic occurred in the Bengal region of India, near Calcutta starting in 1817 through 1824. The disease dispersed from India to Southeast Asia, the Middle East, Europe, and Eastern Africa.<ref name="Hays">{{cite book|url=https://books.google.com/books?id=GyE8Qt-kS1kC|title=Epidemics and Pandemics: Their Impacts on Human History| vauthors = Hays JN |publisher=[[Company:ABC-CLIO|ABC-CLIO]]|year=2005|isbn=978-1-85109-658-9|page=193}}</ref> The movement of British Army and Navy ships and personnel is believed to have contributed to the range of the pandemic, since the ships carried people with the disease to the shores of the Indian Ocean, from Africa to Indonesia, and north to China and Japan.<ref>{{Citation|last=McNeill|first=William H | name-list-style = vanc |title=Plagues and People|page=268}}.</ref>

The second pandemic lasted from 1826 to 1837 and particularly affected North America and Europe. Advancements in transportation and global trade, and increased human migration, including soldiers, meant that more people were carrying the disease more widely.<ref>{{cite book|title=Something New Under The Sun: An Environmental History of the Twentieth Century World (The Global Century Series).|author=McNeil J}}</ref>

The third pandemic erupted in 1846, persisted until 1860, extended to North Africa, and reached North and South America. It was introduced to North America at Quebec, Canada, via Irish immigrants from the Great Famine. In this pandemic, Brazil was affected for the first time.

The fourth pandemic lasted from 1863 to 1875, spreading from India to Naples and Spain, and reaching the United States at New Orleans, Louisiana in 1873. It spread throughout the Mississippi River system on the continent.

The fifth pandemic was from 1881 to 1896. It started in India and spread to Europe, Asia, and South America. The sixth pandemic ran from 1899 to 1923. These epidemics had a lower number of fatalities because physicians and researchers had a greater understanding of the cholera bacteria. Egypt, the Arabian peninsula, Persia, India, and the Philippines were hit hardest during these epidemics. Other areas, such as Germany in 1892 (primarily the city of Hamburg, where more than 8.600 people died)<ref>Richard Evans: ''Death in Hamburg: Society and Politics in the Cholera Years, 1830–1910.'' London 1987</ref> and Naples from 1910 to 1911, also had severe outbreaks.

The seventh pandemic originated in 1961 in Indonesia and is marked by the emergence of a new strain, nicknamed ''El Tor'', which still persists ({{as of|2018|lc=y}}<ref>{{Cite web|url=https://www.cdc.gov/cholera/index.html|title=Cholera – Vibrio cholerae infection {{!}} Cholera {{!}} CDC|date=2017-05-16|website=www.cdc.gov|language=en-us|access-date=2018-04-04}}</ref>) in developing countries.<ref>{{cite book|url=https://archive.org/details/plaguesworldhist00aber|url-access=limited|title=Plagues in World History|last=Aberth|first=John| name-list-style = vanc |publisher=Rowman & Littlefield|year=2011|isbn=978-0-7425-5705-5|location=Lanham, MD|page=[https://archive.org/details/plaguesworldhist00aber/page/n114 102]}}</ref> This pandemic had initially subsided about 1975 and was thought to have ended, but, as noted, it has persisted. There were a rise in cases in the 1990s and since.

Cholera became widespread in the 19th century.<ref>{{cite journal |last1=Huber |first1=Valeska |title=Pandemics and the politics of difference: rewriting the history of internationalism through nineteenth-century cholera |journal=Journal of Global History |date=November 2020 |volume=15 |issue=3 |pages=394–407 |doi=10.1017/S1740022820000236 |s2cid=228940685 |doi-access=free }}</ref> Since then it has killed tens of millions of people.<ref>Kelley Lee (2003) ''Health impacts of globalization: towards global governance''. Palgrave Macmillan. p.131. {{ISBN|0-333-80254-3}}</ref> In [[Place:Russian Empire|Russia]] alone, between 1847 and 1851, more than one million people died from the disease.<ref>Geoffrey A. Hosking (2001). ''[https://books.google.com/books?id=oh-5AAmboMUC&pg=PA9 Russia and the Russians: a history]''. Harvard University Press. p.&nbsp;9. {{ISBN|0-674-00473-6}}</ref> It killed 150,000 Americans during the second pandemic.<ref>{{Cite book | author = Byrne JP | title = Encyclopedia of Pestilence, Pandemics, and Plagues: A–M | url = https://books.google.com/books?id=kRAInwEACAAJ| publisher = ABC-CLIO | year = 2008 | page = 99 | isbn = 978-0-313-34102-1}}</ref> Between 1900 and 1920, perhaps eight million people died of cholera in India.<ref>J. N. Hays (2005). ''[https://books.google.com/books?id=GyE8Qt-kS1kC&pg=PA347 Epidemics and pandemics: their impacts on human history]''. p.347. {{ISBN|1-85109-658-2}}</ref> Cholera officially became the first reportable disease in the United States due to the significant effects it had on health.<ref name=Lancet2004 /> John Snow, in {{wipe|England}}, in 1854 was the first to identify the importance of contaminated water as its source of transmission.<ref name=Lancet2004 /> Cholera is now no longer considered a pressing health threat in Europe and North America due to filtering and [[Chemistry:Water chlorination|chlorination]] of water supplies, but it still strongly affects populations in developing countries.

In the past, vessels flew a yellow [[Medicine:Quarantine|quarantine]] flag if any crew members or passengers had cholera. No one aboard a vessel flying a yellow flag would be allowed ashore for an extended period, typically 30 to 40 days.<ref>{{cite journal | vauthors = Sehdev PS | title = The origin of quarantine | journal = Clinical Infectious Diseases | volume = 35 | issue = 9 | pages = 1071–2 | date = November 2002 | pmid = 12398064 | doi = 10.1086/344062 | doi-access = free }}</ref>

Historically many different claimed remedies have existed in folklore. Many of the older remedies were based on the miasma theory, that the disease was transmitted by bad air. Some believed that abdominal chilling made one more susceptible, and flannel and [[Medicine:Cholera belt|cholera belt]]s were included in army kits.<ref>{{cite journal | vauthors = Renbourn ET | title = The history of the flannel binder and cholera belt | journal = Medical History | volume = 1 | issue = 3 | pages = 211–25 | date = July 1957 | pmid = 13440256 | pmc = 1034286 | doi = 10.1017/S0025727300021281 }}</ref> In the 1854–1855 outbreak in Naples, homeopathic [[Chemistry:Camphor|camphor]] was used according to Hahnemann.<ref>[http://www.legatum.sk/en:ahr:bayes-cholera-as-treated-by-dr-rubini-158-10355 www.legatum.sk] {{webarchive|url=https://web.archive.org/web/20130514193601/http://www.legatum.sk/en%3Aahr%3Abayes-cholera-as-treated-by-dr-rubini-158-10355 |date=2013-05-14 }}, ''The American Homoeopathic Review'', Vol. 06 No. 11–12, 1866, pages 401–403</ref> T. J. Ritter's ''Mother's Remedies'' book lists tomato syrup as a home remedy from northern America. [[Biology:Elecampane|Elecampane]] was recommended in the United Kingdom, according to William Thomas Fernie.<ref name=oldtimeremedies>{{cite web|title=Cholera Infantum, Tomatoes Will Relieve|url=http://www.oldtimeremedies.co.uk/labels/cholera.html|date=October 13, 2008|url-status=dead|archive-url=https://web.archive.org/web/20131224131642/http://www.oldtimeremedies.co.uk/labels/cholera.html|archive-date=December 24, 2013|access-date=February 18, 2013}}</ref> The first effective human vaccine was developed in 1885, and the first effective antibiotic was developed in 1948.

Cholera cases are much less frequent in developed countries where governments have helped to establish water sanitation practices and effective medical treatments.<ref>"Cholera", World Health Organization. [https://www.who.int/topics/cholera/about/en/index.html who.int] {{webarchive|url=https://web.archive.org/web/20131025005943/http://www.who.int/topics/cholera/about/en/index.html |date=2013-10-25 }}</ref> In the 19th century the United States, for example, had a severe cholera problem similar to those in some developing countries. It had three large cholera outbreaks in the 1800s, which can be attributed to ''Vibrio cholerae''{{'s}} spread through interior waterways such as the Erie Canal and the extensive Mississippi River valley system, as well as the major ports along the Eastern Seaboard and their cities upriver.<ref>{{cite journal | vauthors = Pyle GF | title = The diffusion of cholera in the United States in the nineteenth century | journal = Geographical Analysis | volume = 1 | pages = 59–75 | year = 2010 | pmid = 11614509 | doi = 10.1111/j.1538-4632.1969.tb00605.x | doi-access = free }}</ref> The island of Manhattan in New York City touches the Atlantic Ocean, where cholera collected from river waters and ship discharges just off the coast. At this time, New York City did not have as effective a sanitation system as it developed in the later 20th century, so cholera spread through the city's water supply.<ref name="pmid7620035">{{cite journal | vauthors = Lacey SW | title = Cholera: calamitous past, ominous future | journal = Clinical Infectious Diseases | volume = 20 | issue = 5 | pages = 1409–19 | date = May 1995 | pmid = 7620035 | doi = 10.1093/clinids/20.5.1409 | s2cid = 45016958 }}</ref>

Cholera morbus is a historical term that was used to refer to [[Medicine:Gastroenteritis|gastroenteritis]] rather than specifically to what is now defined as the disease of cholera.<ref name="rosenberg">{{cite book|author1=Charles E. Rosenberg|title=The Cholera Years the United States in 1832, 1849, and 1866.|date=2009|publisher=University of Chicago Press|location=Chicago|isbn=978-0-226-72676-2|page=74|url=https://books.google.com/books?id=k2pL9c00rl4C&pg=PA74|url-status=live|archive-url=https://web.archive.org/web/20151109080652/https://books.google.com/books?id=k2pL9c00rl4C&pg=PA74|archive-date=2015-11-09}}</ref>

<gallery>
File:Cholera.jpg|Drawing of [[Social:Death (personification)|Death]] bringing cholera, in ''Le Petit Journal'' (1912).
File:Pedro II of Brazil and ministers of state.JPG|Emperor Pedro II of Brazil visiting people with cholera in 1855.
File:Cholera 395.1.jpg|Hand bill from the New York City Board of Health, 1832—the outdated public health advice demonstrates the lack of understanding of the disease and its causative factors.
</gallery>

=== Research ===

[[File:Robert Koch (Deutsche Cholera-Expedition in Ägypten 1884).jpg|thumb|upright=1.3|Robert Koch (third from the right) on a cholera research expedition in Egypt in 1884, one year after he identified ''V. cholerae'']]
[[File:How to avoid the Cholera 1848.jpg|thumb|upright=1.3|''How to avoid the cholera'' leaflet; Aberystwyth; August 1849]]
One of the major contributions to fighting cholera was made by the physician and pioneer medical scientist John Snow (1813–1858), who in 1854 found a link between cholera and contaminated drinking water.<ref name="Rosenberg">{{cite book |author=Rosenberg, Charles E. |title=The cholera years: the United States in 1832, 1849 and 1866 |publisher=University of Chicago Press |location=Chicago |year=1987 |isbn=978-0-226-72677-9}}</ref> Dr. Snow proposed a microbial origin for epidemic cholera in 1849. In his major "state of the art" review of 1855, he proposed a substantially complete and correct model for the cause of the disease. In two pioneering epidemiological field studies, he was able to demonstrate human [[Earth:Sewage|sewage]] contamination was the most probable disease vector in two major epidemics in London in 1854.<ref>John Snow, [https://books.google.com/books?id=-N0_AAAAcAAJ&pg=PP5 ''The mode of communication of cholera''] {{webarchive|url=https://web.archive.org/web/20151106215135/https://books.google.com/books?id=-N0_AAAAcAAJ&pg=PP5 |date=2015-11-06 }}, 2nd ed. (London, England:  John Churchill, 1855).</ref> His model was not immediately accepted, but it was increasingly seen as plausible as medical microbiology developed over the next 30 years or so. For his work on cholera, John Snow is often regarded as the "Father of Epidemiology".<ref>{{Cite web|last=|first=|date=14 March 2017|title=John Snow: A Legacy of Disease Detectives|url=https://blogs.cdc.gov/publichealthmatters/2017/03/a-legacy-of-disease-detectives/|access-date=2021-01-20|website=US Centers for Disease Control and Prevention|language=en-us}}</ref><ref>{{Cite web|title=Father of Modern Epidemiology|url=https://www.ph.ucla.edu/epi/snow/fatherofepidemiology.html|access-date=2021-01-20|website=www.ph.ucla.edu}}</ref><ref>{{Cite web|last=|first=|date=|title=John Snow|url=https://www.historyofvaccines.org/index.php/content/john-snow|access-date=2021-01-20|website=History of Vaccines|language=en|archive-date=2021-01-28|archive-url=https://web.archive.org/web/20210128091350/https://www.historyofvaccines.org/index.php/content/john-snow|url-status=dead}}</ref>

The bacterium was isolated in 1854 by Italian anatomist [[Biography:Filippo Pacini|Filippo Pacini]],<ref>{{cite journal |first1=Fillipo |last1=Pacini |year=1854 |url=https://books.google.com/books?id=xdtQAAAAcAAJ&pg=PA397 |title=Osservazioni microscopiche e deduzioni patologiche sul cholera asiatico |archive-url=https://web.archive.org/web/20151118081405/https://books.google.com/books?id=xdtQAAAAcAAJ&pg=PA397 |archive-date=18 November 2015 |trans-title=Microscopic observations and pathological deductions on Asiatic cholera |language=it |journal=Gazzetta Medica Italiana |volume=4 |issue=50 |pages=397–401; 405–412 }} Reprinted as: {{cite book |last1=Pacini |first1=Filippo |title=Osservazioni microscopiche e deduzioni patologiche sul cholera asiatico |date=1854 |publisher=Federigo Bencini |url=https://books.google.com/books?id=F9s_AAAAcAAJ |language=it }}</ref> but its exact nature and his results were not widely known. In the same year, the Catalan Joaquim Balcells i Pascual discovered the bacterium.<ref name="Real Academia de la Historia 2018">{{cite web|year=2018|editor=Real Academia de la Historia|title=Joaquín Balcells y Pasqual|url=http://dbe.rah.es/biografias/18541/joaquin-balcells-y-pasqual|archive-url=https://web.archive.org/web/20190708211444/http://dbe.rah.es/biografias/18541/joaquin-balcells-y-pasqual|archive-date=2019-07-08|access-date=2020-08-01|language=es}}</ref><ref>{{cite web|year=2015|editor=Col·legi Oficial de Metges de Barcelona|title=Joaquim Balcells i Pascual|url=http://www.galeriametges.cat/galeria-fitxa.php?icod=EGMM|archive-url=https://web.archive.org/web/20200801110910/http://www.galeriametges.cat/galeria-fitxa.php?icod=EGMM|archive-date=2020-08-01|access-date=2020-08-01|language=ca}}</ref> In 1856 António Augusto da Costa Simões and José Ferreira de Macedo Pinto, two Portuguese researchers, are believed to have done the same.<ref name="Real Academia de la Historia 2018" /><ref>{{cite book|author1=da Costa Simões, António Augusto|url=http://webopac.sib.uc.pt|title=Relatório da Direcção do Hospital de Cholericos de N.S. da Conceição em Coimbra|author2=de Macedo Pinto, José Ferreira|publisher=Imprensa da Universidade. The link leads to a library catalogue where the book can be found|year=1856|location=Coimbra|language=pt}}</ref>

Between the mid-1850s and the 1900s, cities in developed nations made massive investment in clean water supply and well-separated sewage treatment infrastructures. This eliminated the threat of cholera epidemics from the major developed cities in the world. In 1883, [[Biography:Robert Koch|Robert Koch]] identified ''V. cholerae'' with a microscope as the bacillus causing the disease.<ref>{{cite book |last1=Aberth |first1=John |title=Plagues in World History |date=2011 |publisher=Rowman & Littlefield Publishers |isbn=978-1-4422-0796-7 |page=101 }}</ref>

Hemendra Nath Chatterjee, a Bengali scientist, was the first to formulate and demonstrate the effectiveness of oral rehydration salt (ORS) to treat [[Medicine:Diarrhea|diarrhea]].  In his 1953 paper, published in ''The Lancet'', he states that [[Chemistry:Promethazine|promethazine]] can stop [[Medicine:Vomiting|vomiting]] during cholera and then oral rehydration is possible. The formulation of the fluid replacement solution was 4&nbsp;g of [[Chemistry:Sodium chloride|sodium chloride]], 25&nbsp;g of [[Chemistry:Glucose|glucose]] and 1000&nbsp;ml of [[Chemistry:Water|water]].<ref>{{cite journal | vauthors = Ruxin JN | title = Magic bullet: the history of oral rehydration therapy | journal = Medical History | volume = 38 | issue = 4 | pages = 363–97 | date = October 1994 | pmid = 7808099 | pmc = 1036912 | doi = 10.1017/s0025727300036905 }}</ref><ref>{{cite journal | vauthors = Chatterjee HN | title = Control of vomiting in cholera and oral replacement of fluid | journal = Lancet | volume = 265 | issue = 6795 | pages = 1063 | date = November 1953 | pmid = 13110052 | doi = 10.1016/s0140-6736(53)90668-0 }}</ref>

[[File:Medical Scientist Prof. Sambhu Nath De.png|thumb|Prof. Sambhu Nath De, who discovered the cholera toxin and successfully demonstrated the transmission of cholera pathogen by ''bacterial enteric toxin'']]
Indian medical scientist Sambhu Nath De discovered the cholera toxin, the ''animal model of cholera'', and successfully demonstrated the method of transmission of cholera pathogen ''Vibrio cholerae''.<ref>{{Cite web|url=https://inmemoryglobal.com/remembrance/sambhu-nath-de/|title=Sambhu Nath De|website=Inmemory|language=en-US|access-date=2019-12-05|archive-url=https://web.archive.org/web/20191205035801/https://inmemoryglobal.com/remembrance/sambhu-nath-de/|archive-date=2019-12-05|url-status=dead}}</ref>

Robert Allan Phillips, working at US Naval Medical Research Unit Two in Southeast Asia, evaluated the pathophysiology of the disease using modern laboratory chemistry techniques. He developed a protocol for rehydration. His research led the Lasker Foundation to award him its prize in 1967.<ref>{{cite web |url= http://www.laskerfoundation.org/awards/show/treatment-of-cholera/ |title= Albert Lasker Clinical Medical Research Award |publisher= Lasker Foundation |access-date= June 30, 2017 |url-status= dead |archive-url= https://web.archive.org/web/20170901014519/http://www.laskerfoundation.org/awards/show/treatment-of-cholera/ |archive-date= September 1, 2017 }}</ref>

More recently, in 2002, Alam, ''et al.'', studied stool samples from patients at the [[Organization:International Centre for Diarrhoeal Disease Research, Bangladesh|International Centre for Diarrhoeal Disease]] in Dhaka, Bangladesh. From the various experiments they conducted, the researchers found a correlation between the passage of ''V. cholerae'' through the human digestive system and an increased infectivity state. Furthermore, the researchers found the bacterium creates a hyperinfected state where [[Biology:Gene|gene]]s that control biosynthesis of [[Chemistry:Amino acid|amino acid]]s, [[Chemistry:Iron|iron]] uptake systems, and formation of periplasmic nitrate reductase complexes were induced just before defecation. These induced characteristics allow the cholera vibrios to survive in the "rice water" stools, an environment of limited oxygen and iron, of patients with a cholera infection.<ref name="Merrell2002">{{cite journal | vauthors = Merrell DS, Butler SM, Qadri F, Dolganov NA, Alam A, Cohen MB, Calderwood SB, Schoolnik GK, Camilli A | display-authors = 6 | title = Host-induced epidemic spread of the cholera bacterium | journal = Nature | volume = 417 | issue = 6889 | pages = 642–5 | date = June 2002 | pmid = 12050664 | pmc = 2776822 | doi = 10.1038/nature00778 | bibcode = 2002Natur.417..642M }}</ref>

=== Global Strategy ===
In 2017, the WHO launched the "Ending Cholera: a global roadmap to 2030" strategy which aims to reduce cholera deaths by 90% by 2030.<ref name="who_fact">{{Cite web|url=https://www.who.int/news-room/fact-sheets/detail/cholera|title = Cholera}}</ref> The strategy was developed by the Global Task Force on Cholera Control (GTFCC) which develops country-specific plans and monitors progress.<ref>{{Cite web|url=https://www.gtfcc.org/|title=Global Task Force on Cholera Control|website=www.gtfcc.org}}</ref> The approach to achieve this goal combines surveillance, water sanitation, rehydration treatment and oral vaccines.<ref name="who_fact"/> Specifically, the control strategy focuses on three approaches: i) early detection and response to outbreaks to contain outbreaks, ii) stopping cholera transmission through improved sanitation and vaccines in hotspots, and iii) a global framework for cholera control through the GTFCC.<ref name="who_fact"/>

The WHO and the GTFCC do not consider global cholera eradication a viable goal.<ref>{{Cite report |title=Ending Cholera a Global Roadmap to 2030|publisher=Global Task Force on Cholera Control |date=2017 |url=https://www.who.int/cholera/publications/global-roadmap.pdf |archive-url=https://web.archive.org/web/20171018143604/http://www.who.int/cholera/publications/global-roadmap.pdf |archive-date=2017-10-18 |url-status=live |page=18}}</ref> Even though humans are the only host of cholera, the bacterium can persist in the environment without a human host.<ref name="Sack">{{cite journal |last1=Sack |first1=D. A. |title=A new era in the history of cholera: the road to elimination |journal=International Journal of Epidemiology |date=1 December 2013 |volume=42 |issue=6 |pages=1537–1540 |doi=10.1093/ije/dyt229 |pmid=24415587 |doi-access=free }}</ref> While global eradication is not possible, elimination of human to human transmission may be possible.<ref name="Sack"/> Local elimination is possible, which has been underway most recently during the 2010s Haiti cholera outbreak. Haiti aims to achieve certification of elimination by 2022.<ref>{{cite book |title=National Plan for the Elimination of Cholera in Haiti 2013-2022 |date=February 2013 |publisher=Republic of Haiti, Ministry of Public Health and Population, National Directorate for Water Supply and Sanitation |url=https://www.paho.org/hq/dmdocuments/2013/cholera-haiti-nat-plan-elim-2013-2022.pdf |archive-url=https://web.archive.org/web/20180629005315/https://www.paho.org/hq/dmdocuments/2013/cholera-haiti-nat-plan-elim-2013-2022.pdf |archive-date=2018-06-29 |url-status=live }}</ref>

The GTFCC targets 47 countries, 13 of which have established vaccination campaigns.<ref name="who_report2020">{{cite book |title=International Coordinating Group (ICG) on Vaccine Provision for Cholera, Meningitis, and Yellow Fever |date=September 2020 |publisher=World Health Organization |isbn=978-92-4-002916-3 |url=https://www.who.int/publications/i/item/9789240029163 }}</ref>

== Society and culture ==

=== Health policy ===
In many developing countries, cholera still reaches its victims through contaminated water sources, and countries without proper sanitation techniques have greater incidence of the disease.<ref>"Cholera vaccines. A brief summary of the March 2010 position paper" (PDF). World Health Organization. Retrieved September 19, 2013.</ref> Governments can play a role in this. In 2008, for example, the Zimbabwean cholera outbreak was due partly to the government's role, according to a report from the James Baker Institute.<ref name="bakerinstitute.org" /> The Haitian government's inability to provide safe drinking water after the 2010 earthquake led to an increase in cholera cases as well.<ref name="pmid21142690">{{cite journal | vauthors = Walton DA, Ivers LC | title = Responding to cholera in post-earthquake Haiti | journal = The New England Journal of Medicine | volume = 364 | issue = 1 | pages = 3–5 | date = January 2011 | pmid = 21142690 | doi = 10.1056/NEJMp1012997 | s2cid = 41672119 | doi-access = free }}</ref>

Similarly, South Africa's cholera outbreak was exacerbated by the government's policy of privatizing water programs. The wealthy elite of the country were able to afford safe water while others had to use water from cholera-infected rivers.<ref name="pmid14758861">{{cite journal | vauthors = Pauw J | title = The politics of underdevelopment: metered to death-how a water experiment caused riots and a cholera epidemic | journal = International Journal of Health Services | volume = 33 | issue = 4 | pages = 819–30 | year = 2003 | pmid = 14758861 | doi = 10.2190/kf8j-5nqd-xcyu-u8q7 | s2cid = 24270235 }}</ref>

According to Rita R. Colwell of the James Baker Institute, if cholera does begin to spread, government preparedness is crucial. A government's ability to contain the disease before it extends to other areas can prevent a high death toll and the development of an epidemic or even pandemic. Effective disease surveillance can ensure that cholera outbreaks are recognized as soon as possible and dealt with appropriately. Oftentimes, this will allow public health programs to determine and control the cause of the cases, whether it is unsanitary water or seafood that have accumulated a lot of ''Vibrio cholerae'' specimens.<ref name="bakerinstitute.org" /> Having an effective surveillance program contributes to a government's ability to prevent cholera from spreading. In the year 2000 in the state of Kerala in India, the Kottayam district was determined to be "Cholera-affected"; this pronouncement led to task forces that concentrated on educating citizens with 13,670 information sessions about human health.<ref name="John, T. Jacob 2004">{{cite journal | vauthors = John TJ, Rajappan K, Arjunan KK | title = Communicable diseases monitored by disease surveillance in Kottayam district, Kerala state, India | journal = The Indian Journal of Medical Research | volume = 120 | issue = 2 | pages = 86–93 | date = August 2004 | pmid = 15347857 |citeseerx=10.1.1.477.3795 }}</ref> These task forces promoted the boiling of water to obtain safe water, and provided chlorine and oral rehydration salts.<ref name="John, T. Jacob 2004" /> Ultimately, this helped to control the spread of the disease to other areas and minimize deaths. On the other hand, researchers have shown that most of the citizens infected during the 1991 cholera outbreak in Bangladesh lived in rural areas, and were not recognized by the government's surveillance program. This inhibited physicians' abilities to detect cholera cases early.<ref name="pmid1500643">{{cite journal |last1=Siddique |first1=AK |last2=Zaman |first2=K |last3=Baqui |first3=AH |last4=Akram |first4=K |last5=Mutsuddy |first5=P |last6=Eusof |first6=A |last7=Haider |first7=K |last8=Islam |first8=S |last9=Sack |first9=RB |title=Cholera Epidemics in Bangladesh: 1985-1991 |journal=Journal of Diarrhoeal Diseases Research |date=1992 |volume=10 |issue=2 |pages=79–86 |jstor=23498147 |pmid=1500643 |url=http://dspace.icddrb.org/jspui/handle/123456789/262 }}</ref>

According to Colwell, the quality and inclusiveness of a country's health care system affects the control of cholera, as it did in the Zimbabwean cholera outbreak.<ref name="bakerinstitute.org" /> While sanitation practices are important, when governments respond quickly and have readily available vaccines, the country will have a lower cholera death toll. Affordability of vaccines can be a problem; if the governments do not provide vaccinations, only the wealthy may be able to afford them and there will be a greater toll on the country's poor.<ref name="sciencedirect.com">{{cite journal | vauthors = DeRoeck D, Clemens JD, Nyamete A, Mahoney RT | title = Policymakers' views regarding the introduction of new-generation vaccines against typhoid fever, shigellosis and cholera in Asia | journal = Vaccine | volume = 23 | issue = 21 | pages = 2762–74 | date = April 2005 | pmid = 15780724 | doi = 10.1016/j.vaccine.2004.11.044 }}</ref><ref>{{cite journal |last1=Choe |first1=Chongwoo |last2=Raschky |first2=Paul A. |title=Media, institutions, and government action: Prevention vs. palliation in the time of cholera |journal=European Journal of Political Economy |date=January 2016 |volume=41 |pages=75–93 |doi=10.1016/j.ejpoleco.2015.11.001 }}</ref> The speed with which government leaders respond to cholera outbreaks is important.<ref>{{cite web|author= Pruyt, Eric |title= Cholera in Zimbabwe |url= http://www.systemdynamics.org/conferences/2009/proceed/papers/P1357.pdf |date= 26 July 2009 |publisher= Delft University of Technology |url-status= dead |archive-url= https://web.archive.org/web/20131020151002/http://www.systemdynamics.org/conferences/2009/proceed/papers/P1357.pdf |archive-date= 20 October 2013 }}</ref>

Besides contributing to an effective or declining public health care system and water sanitation treatments, government can have indirect effects on cholera control and the effectiveness of a response to cholera.<ref name="Kapp, Clare 2009">{{cite journal |last1=Kapp |first1=Clare |title=Zimbabwe's humanitarian crisis worsens |journal=The Lancet |date=February 2009 |volume=373 |issue=9662 |pages=447 |doi=10.1016/s0140-6736(09)60151-3 |pmid=19205080 |s2cid=5267332 |doi-access=free }}</ref> A country's government can impact its ability to prevent disease and control its spread. A speedy government response backed by a fully functioning health care system and financial resources can prevent cholera's spread. This limits cholera's ability to cause death, or at the very least a decline in education, as children are kept out of school to minimize the risk of infection.<ref name="Kapp, Clare 2009" /> Inversely, poor government response can lead to civil unrest and [[Medicine:Cholera riots|cholera riots]].<ref>{{cite news|url=https://www.google.com/hostednews/afp/article/ALeqM5ghlWQu4P1ofFBBy7jGwvtexoj6dw|title=AFP: Riot police break up Zimbabwe protests as cholera deaths mount |agency=AFP |access-date=25 June 2017}}</ref>

=== Notable cases ===
<!-- References are essential and unreferenced additions will be removed. -->
* Tchaikovsky's death has traditionally been attributed to cholera, most probably contracted through drinking contaminated water several days earlier.<ref>Brown, ''Man and Music'', 430–32; Holden, 371; Warrack, ''Tchaikovsky'', 269–270.</ref> Tchaikovsky's mother died of cholera,<ref>David Brown, ''Early Years'', 46.</ref> and his father became sick with cholera at this time but made a full recovery.<ref>Holden, 23.</ref> Some scholars, however, including English musicologist and Tchaikovsky authority David Brown and biographer Anthony Holden, have theorized that his death was a suicide.<ref>Brown, ''Man and Music'', 431–35; Holden, 373–400.</ref>
* 2010s Haiti cholera outbreak. Ten months after the 2010 earthquake, an outbreak swept over Haiti, traced to a {{wipe|United Nations}} base of peacekeepers from Nepal.<ref>{{cite journal | vauthors = Orata FD, Keim PS, Boucher Y | title = The 2010 cholera outbreak in Haiti: how science solved a controversy | journal = PLOS Pathogens | volume = 10 | issue = 4 | pages = e1003967 | date = April 2014 | pmid = 24699938 | pmc = 3974815 | doi = 10.1371/journal.ppat.1003967 | doi-access = free }}</ref> This marks the worst cholera outbreak in recent history, as well as the best documented cholera outbreak in modern public health.
* Adam Mickiewicz, Polish poet and novelist, is thought to have died of cholera in Istanbul in 1855.
* [[Biography:Nicolas Léonard Sadi Carnot|Sadi Carnot]], physicist, a pioneer of thermodynamics (d. 1832)<ref>Asimov, Isaac (1982), Asimov's Biographical Encyclopedia of Science and Technology (2nd rev. ed.), Doubleday</ref>
* Charles X, King of France (d. 1836)<ref>Susan Nagel, ''Marie Thérèse: Child of Terror'', p. 349–350.</ref>
* James K. Polk, eleventh president of the United States (d. 1849)<ref>{{cite book |author=Haynes SW |title=James K. Polk and the Expansionist Impulse |publisher=Longman |location=New York |page=[https://archive.org/details/jameskpolkexpans00hayn/page/191 191] |isbn=978-0-673-99001-3 |year=1997 |url=https://archive.org/details/jameskpolkexpans00hayn/page/191 }}</ref>
* Carl von Clausewitz, [[Place:Prussia|Prussia]]n soldier and German military theorist (d. 1831)<ref>Smith, Rupert, ''The Utility of Force'', Penguin Books, 2006, page 57</ref>
* Elliot Bovill, Chief Justice of the Straits Settlements (1893)<ref>{{Cite news|url=https://archive.org/details/selangor-journal-1893v1/page/225?q=%22sir+elliot+bovill%22 |newspaper=Selangor Journal |title=Notes and News |date=7 April 1893 |page=1}}</ref>
*[[Biography:Nikola Tesla|Nikola Tesla]], Serbian-American [[Social:Inventor|inventor]], [[Engineering:Engineer|engineer]] and [[Futurist|futurist]] known for his contributions to the design of the modern [[Physics:Alternating current|alternating current]] (AC) electricity supply system, contracted cholera in 1873 at the age of 17. He was bedridden for nine months, and near death multiple times, but survived and fully recovered.

===In popular culture===
Unlike [[Medicine:Tuberculosis|tuberculosis]] ("consumption") which in literature and the arts was often romanticized as a disease of denizens of the demimonde or those with an artistic temperament,<ref>[[Biography:Susan Sontag|Sontag Susan]] (1977) ''Illness as Metaphor / AIDS and Its Metaphors''. New York: Picador. {{isbn|0-312-42013-7}}</ref> cholera is a disease which almost entirely affects the poor living in unsanitary conditions. This, and the unpleasant course of the disease – which includes voluminous "rice-water" diarrhea, the hemorrhaging of liquids from the mouth, and violent muscle contractions which continue even after death – has discouraged the disease from being romanticized, or even being factually presented in popular culture.<ref name="snowden" />
* The 1889 novel ''Mastro-don Gesualdo'' by Giovanni Verga presents the course of a cholera epidemic across the island of [[Place:Sicily|Sicily]], but does not show the suffering of those affected.<ref name="snowden" />
* In [[Biography:Thomas Mann|Thomas Mann]]'s novella ''Death in Venice'', first published in 1912 as ''Der Tod in Venedig'', Mann "presented the disease as emblematic of the final 'bestial degradation' of the sexually transgressive author Gustav von Aschenbach." Contrary to the actual facts of how violently cholera kills, Mann has his protagonist die peacefully on a beach in a deck chair.  Luchino Visconti's 1971 film version also hid from the audience the actual course of the disease.<ref name="snowden" />  Mann's novella was also made into an opera by Benjamin Britten in 1973, his last one, and into a ballet by John Neumeier for his Hamburg Ballet company, in December 2003.*
* ''The Horseman on the Roof'' (orig. French ''Le Hussard sur le toit'') is a 1951 adventure novel written by Jean Giono. It tells the story of Angelo Pardi, a young Italian carbonaro colonel of hussars, caught up in the 1832 cholera epidemic in Provence. In 1995, it was made into a film of the same name directed by Jean-Paul Rappeneau.<ref>{{cite news |last1=Holden |first1=Stephen |title=Film Review – The Horseman on the Roof |url=https://archive.nytimes.com/www.nytimes.com/library/filmarchive/horseman_on_the_roof.html |work=The New York Times |date=17 May 1996}}</ref>
* In Gabriel Garcia Márquez's 1985 novel ''Love in the Time of Cholera'', cholera is "a looming background presence rather than a central figure requiring vile description."<ref name="snowden">{{cite book | last = Snowden |first = Frank M. | name-list-style = vanc | title = Epidemics and Society: From the Black Death to the Present | place = New Haven, Connecticut | publisher = Yale University Press | year = 2019 | isbn = 978-0-300-19221-6| pages=239–240}}</ref>  The novel was adapted in 2007 for the film of the same name directed by Mike Newell.

== Country examples ==

=== Zambia ===
In Zambia, widespread cholera outbreaks have occurred since 1977, most commonly in the capital city of Lusaka.<ref>{{cite journal|display-authors=6|vauthors=Mwaba J, Debes AK, Shea P, Mukonka V, Chewe O, Chisenga C, Simuyandi M, Kwenda G, Sack D, Chilengi R, Ali M|date=April 2020|title=Identification of cholera hotspots in Zambia: A spatiotemporal analysis of cholera data from 2008 to 2017|journal=PLOS Neglected Tropical Diseases|volume=14|issue=4|pages=e0008227|doi=10.1371/journal.pntd.0008227|pmc=7159183|pmid=32294084 |doi-access=free }}</ref> In 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of ''[[Biology:Vibrio cholerae|Vibrio cholerae]]'' O1, biotype El Tor, serotype Ogawa, from stool samples from two patients with acute watery diarrhea. There was a rapid increase in the number of cases from several hundred cases in early December 2017 to approximately 2,000 by early January 2018.<ref name="Sinyange et al 2018">{{cite journal |last1=Sinyange |first1=Nyambe |last2=Brunkard |first2=Joan M. |last3=Kapata |first3=Nathan |last4=Mazaba |first4=Mazyanga Lucy |last5=Musonda |first5=Kunda G. |last6=Hamoonga |first6=Raymond |last7=Kapina |first7=Muzala |last8=Kapaya |first8=Fred |last9=Mutale |first9=Lwito |last10=Kateule |first10=Ernest |last11=Nanzaluka |first11=Francis |last12=Zulu |first12=James |last13=Musyani |first13=Chileshe Lukwesa |last14=Winstead |first14=Alison V. |last15=Davis |first15=William W. |last16=N'cho |first16=Hammad S. |last17=Mulambya |first17=Nelia L. |last18=Sakubita |first18=Patrick |last19=Chewe |first19=Orbie |last20=Nyimbili |first20=Sulani |last21=Onwuekwe |first21=Ezinne V.C. |last22=Adrien |first22=Nedghie |last23=Blackstock |first23=Anna J. |last24=Brown |first24=Travis W. |last25=Derado |first25=Gordana |last26=Garrett |first26=Nancy |last27=Kim |first27=Sunkyung |last28=Hubbard |first28=Sydney |last29=Kahler |first29=Amy M. |last30=Malambo |first30=Warren |last31=Mintz |first31=Eric |last32=Murphy |first32=Jennifer |last33=Narra |first33=Rupa |last34=Rao |first34=Gouthami G. |last35=Riggs |first35=Margaret A. |last36=Weber |first36=Nicole |last37=Yard |first37=Ellen |last38=Zyambo |first38=Khozya D. |last39=Bakyaita |first39=Nathan |last40=Monze |first40=Namani |last41=Malama |first41=Kennedy |last42=Mulwanda |first42=Jabbin |last43=Mukonka |first43=Victor M. |title=Cholera Epidemic — Lusaka, Zambia, October 2017–May 2018 |journal=MMWR. Morbidity and Mortality Weekly Report |date=18 May 2018 |volume=67 |issue=19 |pages=556–559 |doi=10.15585/mmwr.mm6719a5 |pmid=29771877 |pmc=6048949 }}</ref> With intensification of the rains, new cases increased on a daily basis reaching a peak on the first week of January 2018 with over 700 cases reported.<ref>{{Cite journal|date=1 October 2020|title=Emergency Plan of Action Final Report Zambia: Cholera Outbreak Lusaka|url=https://reliefweb.int/sites/reliefweb.int/files/resources/MDRZM011dfr.pdf |archive-url=https://web.archive.org/web/20210420022015/https://reliefweb.int/sites/reliefweb.int/files/resources/MDRZM011dfr.pdf |archive-date=2021-04-20 |url-status=live|via=International Federation of Red Cross and Red Crescent Societies}}</ref>

In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples.<ref name="Sinyange et al 2018"/>

The Zambian Ministry of Health implemented a reactive one-dose Oral Cholera Vaccine (OCV) campaign in April 2016 in three Lusaka compounds, followed by a pre-emptive second-round in December.<ref>{{cite journal|display-authors=6|vauthors=Heyerdahl LW, Pugliese-Garcia M, Nkwemu S, Tembo T, Mwamba C, Demolis R, Chilengi R, Gessner BD, Guillermet E, Sharma A|date=May 2019|title="It depends how one understands it:" a qualitative study on differential uptake of oral cholera vaccine in three compounds in Lusaka, Zambia|url= |journal=BMC Infectious Diseases|volume=19|issue=1|pages=421|doi=10.1186/s12879-019-4072-6|pmc=6518637|pmid=31088376 |doi-access=free }}</ref>

=== India ===
The city of [[Place:Kolkata|Kolkata]], {{wipe|India}} in the state of West Bengal in the Ganges delta has been described as the "homeland of cholera", with regular outbreaks and pronounced seasonality. In India, where the disease is [[Biology:Endemism|endemic]], cholera outbreaks occur every year between [[Earth:Dry season|dry season]]s and rainy seasons. India is also characterized by high population density, unsafe drinking water, open drains, and poor sanitation which provide an optimal niche for survival, sustenance and transmission of ''Vibrio cholerae''.<ref>{{cite journal|vauthors=Mandal S|date=July 2011|title=Cholera epidemic in and around Kolkata, India: endemicity and management|journal=Oman Medical Journal|volume=26|issue=4|pages=288–9|doi=10.5001/omj.2011.71|pmc=3191718|pmid=22043439}}</ref>

=== Democratic Republic of Congo ===
In Goma in the Democratic Republic of Congo, cholera has left an enduring mark on human and medical history. Cholera pandemics in the 19th and 20th centuries led to the growth of epidemiology as a science and in recent years it has continued to press advances in the concepts of [[Medicine:Disease ecology|disease ecology]], basic membrane biology, and transmembrane signaling and in the use of scientific information and treatment design.<ref>{{cite journal |last1=Lacey |first1=S. W. |title=Cholera: Calamitous Past, Ominous Future |journal=Clinical Infectious Diseases |date=1 May 1995 |volume=20 |issue=5 |pages=1409–1419 |doi=10.1093/clinids/20.5.1409 |pmid=7620035 |jstor=4458566 }}</ref>

== Explanatory notes ==
{{Reflist|group=note}}

== References ==
{{Reflist}}

==Further reading==
* {{cite journal |last1=Arnold |first1=David |title=Cholera and Colonialism in British India |journal=Past & Present |date=1986 |volume=113 |issue=113 |pages=118–151 |doi=10.1093/past/113.1.118 |jstor=650982 |pmid=11617906 }}
* {{cite journal |last1=Azizi |first1=MH |last2=Azizi |first2=F |title=History of Cholera Outbreaks in Iran during the 19th and 20th Centuries |journal=Middle East Journal of Digestive Diseases |date=January 2010 |volume=2 |issue=1 |pages=51–55 |pmid=25197514 |pmc=4154910 }}
* Bilson, Geoffrey. ''A Darkened House: Cholera in Nineteenth-Century Canada'' (U of Toronto Press, 1980).
* {{cite journal |last1=Cooper |first1=Donald B. |title=The New 'Black Death': Cholera in Brazil, 1855–1856 |journal=Social Science History |date=1986 |volume=10 |issue=4 |pages=467–488 |doi=10.2307/1171027 |jstor=1171027 |pmid=11618140 }}
* {{cite book |last1=Echenberg |first1=Myron |title=Africa in the Time of Cholera: A History of Pandemics from 1817 to the Present |date=2011 |publisher=Cambridge University Press |isbn=978-0-521-18820-3 }}
* {{cite journal |last1=Evans |first1=Richard J. |title=Epidemics and Revolutions: Cholera in Nineteenth-Century Europe |journal=Past & Present |date=1988 |volume=120 |issue=120 |pages=123–146 |doi=10.1093/past/120.1.123 |jstor=650924 |pmid=11617908 }}
* {{cite book |last1=Evans |first1=Richard J. |title=Death in Hamburg: Society and Politics in the Cholera Years |date=2005 |publisher=Penguin |isbn=978-0-14-303636-4 }}
* Gilbert, Pamela K. ''Cholera and Nation: Doctoring the Social Body in Victorian England" (SUNY Press, 2008).
* {{Cite book|last=Hamlin|first=Christopher|title=Cholera: The Biography|publisher=Oxford University Press|year=2009}}
* {{cite journal |last1=Huber |first1=Valeska |title=Pandemics and the politics of difference: rewriting the history of internationalism through nineteenth-century cholera |journal=Journal of Global History |date=November 2020 |volume=15 |issue=3 |pages=394–407 |doi=10.1017/S1740022820000236 |s2cid=228940685 |doi-access=free }}
* {{cite journal |last1=Huber |first1=Valeska |title=The Unification of the Globe by Disease? The International Sanitary Conferences on Cholera, 1851–1894 |journal=The Historical Journal |date=June 2006 |volume=49 |issue=2 |pages=453–476 |doi=10.1017/S0018246X06005280 |s2cid=162994263 }}
* {{cite journal |last1=Jenson |first1=Deborah |last2=Szabo |first2=Victoria |title=Cholera in Haiti and Other Caribbean Regions, 19th Century |journal=Emerging Infectious Diseases |date=November 2011 |volume=17 |issue=11 |pages=2130–2135 |doi=10.3201/eid1711.110958 |pmid=22099117 |pmc=3310590 }}
* {{cite book |last1=Kotar |first1=S. L. |last2=Gessler |first2=J. E. |title=Cholera: A Worldwide History |date=2014 |publisher=McFarland |isbn=978-0-7864-7242-0 }}
* {{Cite book|last=Kudlick|first=Catherine Jean|title=Cholera in Post-Revolutionary Paris: A Cultural History|publisher=University of California Press|year=1996|location=Berkeley}}
* {{cite journal |last1=Legros |first1=Dominique |title=Global Cholera Epidemiology: Opportunities to Reduce the Burden of Cholera by 2030 |journal=The Journal of Infectious Diseases |date=15 October 2018 |volume=218 |issue=suppl_3 |pages=S137–S140 |doi=10.1093/infdis/jiy486 |pmid=30184102 |pmc=6207143 }}
* {{cite journal |last1=Mukharji |first1=Projit Bihari |title=The 'Cholera Cloud' in the Nineteenth-Century 'British World': History of an Object-Without-an-Essence |journal=Bulletin of the History of Medicine |date=2012 |volume=86 |issue=3 |pages=303–332 |id={{INIST|26721136}} {{Project MUSE|492086}} |doi=10.1353/bhm.2012.0050 |pmid=23241908 |jstor=26305866 |s2cid=207267413 }}
* {{cite book|last1=Rosenberg|first1=Charles E.|title=The Cholera Years: The United States in 1832, 1849, and 1866|date=1987|publisher=University of Chicago Press|isbn=978-0-226-72677-9|}}
* {{cite journal |last1=Roth |first1=Mitchel |title=Cholera, Community, and Public Health in Gold Rush Sacramento and San Francisco |journal=Pacific Historical Review |date=1997 |volume=66 |issue=4 |pages=527–551 |doi=10.2307/3642236 |jstor=3642236 }}
* Snowden, Frank M. ''Naples in the Time of Cholera, 1884-1911'' (Cambridge UP, 1995).
* Vinten-Johansen, Peter, ed. ''Investigating Cholera in Broad Street: A History in Documents'' (Broadview Press, 2020). regarding 1850s in England.
* Vinten-Johansen, Peter, et al. ''Cholera, chloroform, and the science of medicine: a life of John Snow'' (2003).

== External links ==
* [https://web.archive.org/web/20130622144054/http://www.who.int/cholera/technical/prevention/control/en/ Prevention and control of cholera outbreaks: WHO policy and recommendations]
* [https://web.archive.org/web/20060324155246/http://www.who.int/cholera/ Cholera]—[[Organization:World Health Organization|World Health Organization]]
* [https://www.cdc.gov/cholera/index.html Cholera – ''Vibrio cholerae'' infection]—Centers for Disease Control and Prevention

{{Medical resources
|DiseasesDB = 29089
|ICD11 = {{ICD11|1A00}}
|ICD10 = {{ICD10|A00}}
|ICD9 = {{ICD9|001}}
|MedlinePlus = 000303
|eMedicineSubj = med
|eMedicineTopic = 351
|eMedicine_mult =
|MeshID = D002771
|Orphanet = 173
}}
{{Diseases of Poverty}}
{{Bacterial diseases}}

[[Category:Cholera| ]]
[[Category:Tropical diseases]]
[[Category:Wikipedia medicine articles ready to translate]]

{{Sourceattribution|Cholera}}