Cholera: causes, symptoms, treatment and effective prevention methods

In Romania, a cholera-like bacteria was recently identified in a patient. It is a non-toxigenic cholera vibrio that does not produce the classic symptoms of the disease. A classical case of cholera has also been confirmed on the border with Romania in Bulgaria in a patient who had visited India.

Cholera is a severe infectious disease transmitted through contaminated food or water and can be life-threatening if left untreated. In this article you will find out more about how it is transmitted, what symptoms occur, what the appropriate treatment is and how to prevent infection.

What is cholera?

Cholera is an acute infection of the small intestine, caused by the bacterium Vibrio cholerae (cholera vibrio), a member of the Vibrionaceae family. There are several serogroups, but only two cause outbreaks: O1 (the recent ones) and O139 (sporadic in the past, first identified in 1992 in Bangladesh and never outside Asia) (WHO, Cholera, 2024)

The bacterium has the ability to produce cholera toxin, a type of enterotoxin that damages intestinal cells, leads to diarrhea and rapid loss of fluids and electrolytes (Claeson & Waldman, 2024).

How is cholera transmitted?

It is spread by the fecal-oral route through ingestion of water or food (raw fruits and vegetables, cereals, seafood) contaminated with the feces of a patient infected with cholera vibrio. If the water is not treated before drinking, cooking or washing, transmission is easy.

Cholera is not normally transmitted by direct person-to-person contact, but without proper hygiene this can still happen. (***, Cholera, 2021) Asymptomatic patients can also transmit the bacteria as it is excreted through stool for 7 to 14 days. (***, Cholera, 2022)

Who is at risk of infection?

Those who live in unsanitary areas and drink untreated water or eat raw/undercooked/undercooked food are at the highest risk of illness. People traveling to outbreak areas or living with infected people are also at risk.

The bacterium is destroyed by hydrochloric acid in the stomach, so the use of drugs that neutralize (antacids – e.g. calcium or magnesium carbonate) or decrease gastric secretion (proton pump inhibitors – e.g. omeprazole, pantoprazole or H2-receptor antagonists – e.g. ranitidine, famotidine) may increase the risk of illness with more severe symptoms. (***, Cholera, 2022)

According to one study, chronic Helicobacter pylori infection has been associated with chronic gastritis, decreased gastric acid production and an increased risk of life-threatening cholera. (León-Barúa, et al., 2006)

Epidemiologists observed four decades ago that people with blood type O were more likely to be hospitalized for cholera than those with other blood types, a point also noted by researchers at Washington University School of Medicine (St. Louis) (FM, et al., 2016).

What are the signs and symptoms of cholera?

Some people show no symptoms, others will have mild symptoms, but about 1 in 10 infected patients may suddenly develop severe ones after an incubation of 12 hours to 5 days: watery diarrhea (often has a pale, milky appearance that resembles water in which rice has been washed), nausea and vomiting (which can last for hours), dehydration (up to 1 L/hr in adults and 20 cc/kg body/hr; a loss of 10% or more of body weight indicates severe dehydration). Children may also present with lethargy, fever and convulsions.

Signs and symptoms of dehydration include severe thirst, dry and unelastic skin, little or no urination, dry mouth, dry mouth, sunken eyes, fatigue, irritability, low blood pressure and irregular heartbeat. (***, Cholera, 2022)

What are the complications of cholera?

Very high fluid losses cause electrolyte imbalances that can lead to muscle cramps and hypovolemic shock (when low blood volume causes a drop in blood pressure and the amount of oxygen in the body). Without proper treatment it can cause death within minutes. (***, About Cholera)

Other complications that can lead to death include:

  • hypoglycemia (low blood sugar) when the patient is too weak to eat (children are usually more at risk)
  • hypokalemia (a low potassium level) which affects heart and nerve function
  • renal failure (when the kidneys lose their filtering ability and excess fluid, electrolytes and breakdown products accumulate in the body) which is often associated with hypovolemic shock.

When is it necessary to consult a doctor?

  • If severe diarrhea occurs after visiting a cholera outbreak area
  • If you have diarrhea (especially severe diarrhea) and you think you have been in contact with an infected person

How can cholera be diagnosed?

The diagnosis of cholera can be made on the basis of the symptoms listed above, especially if the ill person has recently traveled to cholera-risk or unsanitary areas or eaten shellfish. Fecal samples will be sent to the laboratory (coproculture), although the result of the analysis is not necessary to start the vital treatment quickly.

What is the treatment for cholera?

Death can occur within hours without proper treatment. It consists of:

  • Oral or intravenous rehydration
  • When fluid loss is 5-10% of body weight, an oral rehydration solution (ORS: a measured mixture of glucose, sodium chloride, potassium chloride and trisodium citrate) can be given, which can shorten the duration of diarrhea and the amount of fluid lost through stool (Medecins Sans Frontiers, ***)
  • Intravenous rehydration is needed for the most severely dehydrated

There is a standard WHO/UNICEF sachet of oral rehydration solution that is used worldwide to treat diarrhea. The contents are dissolved in one liter of clean water (drinking, bottled or boiled). Adult patients may require up to 6 liters of ORS to treat moderate dehydration on the first day. (***, Oral rehydration salts and zinc). According to UNICEF and WHO, oral rehydration should be combined with advice on good feeding practices:

  • For treating children under 5 years of age, zinc supplementation (20 mg zinc/day for 10 to 14 days) and continued breastfeeding during periods of diarrhea protect against dehydration, reduce protein and calorie intake, with a good impact on reducing diarrhea and malnutrition (***, 2006)
  • Taking antibiotics for severe infection shortens its duration

How to prevent infection?

Wash your hands with soap and water at least 15 seconds after using the toilet or caring for a person with diarrhea and before handling food. If soap and water are not available, you can use a disinfectant with at least 70% alcohol.(***, Preventing Cholera: Five Basic Steps, 2024)

Use surface disinfectants based on at least 60% alcohol or 0.2% chlorine. (***, Preventing Cholera: Five Basic Steps, 2024)

Use bottled water (even for brushing your teeth or face) or water that you have previously boiled (1 minute) or disinfected. Do not use ice unless you have used safe water. (***, Preventing Cholera: Five Basic Steps, 2024)

Eat enough cooked food and avoid street-food and sushi. Avoid salads and fruits that cannot be cleaned (***, Cholera, 2022).

Avoid traveling to areas known to have cholera outbreaks. Also avoid importing food from those areas.

Currently, there are 3 licensed oral cholera vaccines (OCVs): Dukoral®, Shanchol™ and Euvichol-Plus®. All require 2 doses for complete protection (WHO, 2017). Vaccines should be used in cholera endemic areas, in humanitarian crises with high risk of infection and during cholera outbreaks. (***, Cholera, 2024)

Cholera in Romania

On July 13, 1913, during the Second Balkan War, the first case of cholera occurred among Romanian military personnel. Although the Romanian army did not fire a single shot in the war, intervening too late, it nevertheless suffered losses due to the cholera epidemic: between 1087 and 1611 deaths and around 15,000 people fell ill. Queen Mary herself, then Princess Princess, with the help of Professor Dr. Ioan Cantacuzino and Colonel Slătineanu, crossed the Danube and donned her Red Cross uniform to offer her help to the soldiers in the makeshift field hospitals in Bulgaria, without any fear that they might become infected. The energy and courage he showed then led the king to allow him to run the Zimnicea camp for theolera camp. (Theodorescu, Bulei, Drăgan, & Ion, 2018)

Quarantine measures were not respected by all military commanders and cholera reached north of the Danube. Based on the research on cholera vibrio, the physician Ion Cantacuzino (appointed inspector general of the Directorate of the Sanitary Service of the Great Headquarters), implemented a cholera vaccination method, called the “Cantacuzino Method”, still used today in areas where cholera cases occur. Thanks to the vaccination and all the corrective and preventive measures taken within a short time (setting up hospitals and lazarettos, installing two sanitary cordons, sanitizing the localities, etc.), the epidemic was halted until the troops returned to the garrisons in the country. Cantacuzino thus became the first doctor in the world to successfully use vaccination on a large scale in the midst of an epidemic outbreak (Stoica, 2020).

The cholera epidemic also manifested itself in the civilian population with many illnesses and deaths. Data on its evolution in Romania were identified in the communications of the Ministry of Interior, the General Directorate of the Sanitary Service found in military documents (Stoica, 2020).

Cholera also claimed victims after the Second World War, with the last epidemic recorded in 1991. (Manolache, ***)

According to the information provided by the National Institute of Public Health, no cases of cholera have been recorded in Romania for more than 30 years (***, 2023).

According to the provisions of Government Decision no. 657/2022, health care providers are obliged to report to the DSP the communicable diseases foreseen in the single communicable disease case report form (MS, 2023). Cholera is considered a communicable disease. Suspected cholera patients are hospitalized in the Infectious Diseases Department and case confirmation is based on the bacteriological diagnosis established by the National Institute of Medical-Military Research and Development Cantacuzino. (***, 2017)

Cholera is a severe infectious disease, but it is preventable and treatable when diagnosed early. Understanding the causes, symptoms and methods of transmission is essential to prevent infection. Compliance with hygiene measures and vaccination can significantly reduce the risk of illness.

Note: The information in this article is for information purposes only. If you have specific symptoms, contact your family doctor for advice.

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