Cholera: causes, symptoms, treatment, and effective prevention methods

In Romania, a bacterium similar to the one that causes cholera was recently identified in a patient. It is a non-toxigenic cholera vibrio that does not produce the classic symptoms of the disease. Furthermore, a classic case of cholera was confirmed on the border with Romania, in Bulgaria, involving a patient who had visited India.

Cholera is a severe infectious disease transmitted through contaminated water or food, which can be life-threatening if not treated in time. From this article, you will learn more about how it is transmitted, what symptoms appear, what the appropriate treatment is, and how we can prevent infection.

What is cholera?

Cholera is an acute infection of the small intestine caused by the bacterium Vibrio cholerae (the cholera vibrio), which belongs to the Vibrionaceae family. There are several serogroups, but only two cause outbreaks: O1 (the recent ones) and O139 (in the past, sporadically, 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 affects intestinal cells, leading to diarrhea and rapid loss of fluids and electrolytes (Claeson & Waldman, 2024).

How is cholera transmitted?

It spreads via the fecal-oral route through the ingestion of water or food (raw fruits and vegetables, grains, seafood) contaminated with the feces of a patient infected with the cholera vibrio. If water is not treated before consumption, cooking, or washing, transmission occurs easily.

Typically, cholera is not transmitted through direct contact from one person to another, but without proper hygiene this can still happen. (***, Cholera, 2021) Asymptomatic patients can also transmit the bacterium because it is shed in the stool for 7 to 14 days. (***, Cholera, 2022)

Who is at risk of infection?

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

The bacterium is destroyed by stomach acid, which is why the use of drugs that neutralize (antacids – e.g., calcium or magnesium carbonate) or reduce 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 a study, chronic Helicobacter pylori infection has been associated with chronic gastritis, low 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 finding 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 have no symptoms, others will have mild symptoms, but about 1 in 10 infected patients may suddenly develop severe ones after an incubation period of 12 hours to 5 days: watery diarrhea (often has a pale, milky appearance, resembling water in which rice has been washed), nausea and vomiting (which can last for hours), dehydration (up to 1 L/hour in adults and 20 cc/kg body weight/hour; a loss of 10% or more of body weight indicates severe dehydration). Children may also exhibit lethargy, fever, and convulsions.

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

What are the complications of cholera?

In cases of very high fluid loss, electrolyte imbalances occur, which 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 (low potassium level) which affects heart and nerve function
• kidney failure (when the kidneys lose their filtering capacity and excess fluids, electrolytes, and waste 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 an area where there is a cholera outbreak
• If you have diarrhea (especially severe) and believe you have been in contact with an infected person

How can cholera be diagnosed?

The diagnosis of cholera can be made based on the symptoms listed above, especially if the sick person has recently traveled to high-risk, unsanitary areas or has consumed shellfish. Stool samples will be sent to the laboratory (stool culture), although the test result is not required to quickly begin treatment, which is vital.

What is the treatment for cholera?

Death can occur within hours without proper treatment. Treatment 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 administered, which can shorten the duration of diarrhea and the amount of fluid lost in the stool (Medecins Sans Frontiers, ***)
• In the most severely dehydrated cases, intravenous rehydration is necessary

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

• For treating children under 5, 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 consumption, and have a positive impact on reducing diarrhea and malnutrition (***, 2006)
• The administration of antibiotics in cases of severe infection shortens its duration

How do we prevent infection?

Wash your hands with water and soap for at least 15 seconds after using the toilet or caring for a person with diarrhea and before handling food. If you do not have water and soap available, you can use a hand sanitizer 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 washing your face) or water that you have boiled (1 minute) or disinfected beforehand. Do not use ice unless you have used safe water. (***, Preventing Cholera: Five Basic Steps, 2024)

Consume sufficiently cooked food and avoid street food and sushi. Avoid salads and fruits that cannot be peeled. (***, Cholera, 2022)

Avoid traveling to areas where you know there are cholera outbreaks. Also, avoid importing food from those areas.

Currently, there are 3 authorized oral cholera vaccines (OCVs): Dukoral®, Shanchol™, and Euvichol-Plus®. All require 2 doses for full protection (WHO, 2017). Vaccines should be used in cholera-endemic areas, in humanitarian crises with a 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 appeared among Romanian soldiers. Although the Romanian army did not fire a single shot in this war, intervening too late, it still recorded losses due to the cholera epidemic: between 1087 and 1611 deaths and around 15,000 illnesses. Queen Marie herself, then Princess, with the help of Professor Dr. Ioan Cantacuzino and Colonel Slătineanu, crossed the Danube and donned the Red Cross uniform to offer her help to soldiers in improvised field hospitals in Bulgaria, without any fear of getting infected. The energy and courage shown then led the king to allow her to lead the cholera camp at Zimnicea. (Theodorescu, Bulei, Drăgan, & Ion, 2018)

Quarantine measures were not respected by all military commanders, and cholera reached north of the Danube. Based on research regarding the cholera vibrio, the physician Ion Cantacuzino (appointed Inspector General of the Sanitary Service Directorate at General Headquarters) implemented a method of anti-cholera vaccination, called the "Cantacuzino Method," still used today in areas where there are cholera cases. Thanks to vaccination, as well as all the correction and prevention measures taken shortly thereafter (setting up hospitals and lazarettos, installing two sanitary cordons, cleaning up localities, etc.), the evolution of the epidemic was stopped before the troops returned to their garrisons in the country. Thus, Dr. Cantacuzino became the first in the world to successfully use large-scale vaccination in the middle of an epidemic outbreak. (Stoica, 2020)

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

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

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

According to the provisions of Government Decision no. 657/2022, medical service providers are required to report communicable diseases provided in the single reporting form for communicable disease cases to the Public Health Directorate (DSP) (MS, 2023). Cholera is considered a communicable disease. Patients suspected of having cholera are admitted to the Infectious Diseases Ward, and case confirmation is based on the bacteriological diagnosis established by the Cantacuzino National Military-Medical Research and Development Institute. (***, 2017)

Cholera is a severe infectious disease, but it can be prevented and treated when diagnosed in time. Understanding the causes, symptoms, and transmission methods is essential to prevent infection. Adhering to hygiene measures and vaccination can significantly reduce the risk of illness.

Note: The information in this article is for informational purposes. If you experience symptoms specific to the disease, contact your family doctor to receive the necessary recommendations.

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