Seminar

Cholera
Suman Kanungo, Andrew S Azman, Thandavarayan Ramamurthy, Jaqueline Deen, Shanta Dutta

Cholera was first described in the areas around the Bay of Bengal and spread globally, resulting in seven pandemics Lancet 2022; 399: 1429–40
during the past two centuries. It is caused by toxigenic Vibrio cholerae O1 or O139 bacteria. Cholera is characterised National Institute of Cholera
by mild to potentially fatal acute watery diarrhoeal disease. Prompt rehydration therapy is the cornerstone of and Enteric Diseases,
Kolkata, India (S Kanungo PhD,
management. We present an overview of cholera and its pathogenesis, natural history, bacteriology, and epidemiology,
T Ramamurthy PhD,
while highlighting advances over the past 10 years in molecular epidemiology, immunology, and vaccine development S Dutta MD); Department of
and deployment. Since 2014, the Global Task Force on Cholera Control, a WHO coordinated network of partners, has Epidemiology, Johns Hopkins
been working with several countries to develop national cholera control strategies. The global roadmap for cholera University, Baltimore, MD, USA
(A S Azman PhD); Institute of
control focuses on stopping transmission in cholera hotspots through vaccination and improved water, sanitation,
Global Health, Faculty of
and hygiene, with the aim to reduce cholera deaths by 90% and eliminate local transmission in at least 20 countries Medicine, University of
by 2030. Geneva, Geneva, Switzerland
(A S Azman); Institute of Child
Introduction Vibrio cholerae Health and Human
Development, National
Cholera is a severe and dehydrating diarrhoeal illness, Cholera is caused by the motile, comma shaped, Institutes of Health, University
described as one of the most rapidly fatal human facultative anaerobic, Gram-negative aquatic bacterium, of the Philippines-Manila,
infections if not treated immediately.1 Cholera has Vibrio cholerae. V cholerae naturally exists in marine Manila, Philippines (J Deen MD)

plagued humans for hundreds, if not thousands, of
years, particularly in the areas around the Bay of Bengal,
with some of the first records of cholera-like illness
reported in ancient Sanskrit medical texts written around
500–400 BCE.1 An 1854 cholera outbreak in London, UK,
provided the scene for English physician John Snow to
lay the foundations for modern infectious disease
epidemiology, when he presented strong evidence for the
waterborne transmission of cholera.2,3
Cholera continues to spread globally and has caused
seven pandemics during the past two centuries.4 The
seventh pandemic, which is still ongoing, was first
detected in 1961 in Sulawesi, an island governed by
Indonesia, with the first reports of cholera from Africa
in 1971 and the Americas in 1991.5 Cholera tends to occur
in areas with inadequate access to clean water supply and
sanitation, including those devastated by war or natural
catastrophes.6 Aside from human suffering, cholera
outbreaks can cause substantial economic losses and
overwhelm public health services, further impeding
development.
Since the previous Lancet Seminar in 2017, notable
progress has been achieved in the understanding of the
molecular epidemiology and immune response to
cholera. There have been shifts in the epidemiology and
burden of disease around the world, including the
control of cholera in Haiti after 8 years of sustained
transmission, but also a protracted nationwide outbreak
in Yemen. 2022 marks nearly a decade since an oral
cholera vaccine (OCV) stockpile was created, and both
the availability and use of the vaccine have greatly
increased. In 2017, the Global Task Force on Cholera
Control (GTFCC), a WHO coordinated network of
partners, launched an initiative aiming to reduce cholera
deaths by 90% worldwide, and to eliminate cholera in at
least 20 countries by 2030.7 Since then, several countries
have embarked on the development of bold national
cholera control plans.
environments and is well adapted for, and highly Correspondence to:
Dr Shanta Dutta, National
transmissible to, human hosts. In the aquatic milieu,
Institute of Cholera and Enteric
V cholerae uses chitin from crustaceans as the main Diseases, Kolkata, 700010, India
source of carbon and nitrogen. In humans, V cholerae shanta.niced@icmr.gov.in;
uses intestinal nutrients for colonisation and proliferation. shanta1232001@gmail.com
On the basis of the structure of the lipopolysaccharide,
more than 200 serogroups of V cholerae have been
identified.8 Of these serogroups, O1 and O139 have been
associated with cholera epidemics.5 The cholera toxin
encoding gene is carried by a filamentous bacteriophage,
CTXΦ. The toxin coregulated pilus is responsible for
intestinal colonisation of the bacteria and acts as a CTXΦ
receptor.9
The classical biotype of O1 probably caused the first six
cholera pandemics.10 The seventh pandemic, which
started in the early 1960s, was caused by the O1 El Tor
biotype. Serogroup O139 was first detected in the
Indian subcontinent in 1992 and spread to Asian
countries causing large epidemics. This serogroup was
genetically derived from the seventh pandemic O1 El Tor
V cholerae (7PET) lineage, with modification of the
lipopolysaccharide and inclusion of a capsule
to the parent strain.11 Although many experts believed
O139 would replace pandemic O1 strains, this
replacement never occurred, and isolation of this
serogroup has been uncommon since the early 2000s.
Search strategy and selection strategy criteria
Data for this Seminar were identified in PubMed using the
search string ((cholera [title/abstract]) OR (cholerae [title/
abstract])) for articles published between Jan 1, 2011, and
April 12, 2021, filtered to human-only studies published in
any language. We also included references cited in these
publications and relevant older references from our personal
files. International cholera control, prevention, and treatment
guidelines, and WHO policy documents were also consulted.

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Efflux of fluid with Na+,K+

Cl–, HCO3–, H20
Ingestion of Vibrio cholera via CT-A
contaminated food or water
CT-B

Passage through the

gastric acid barrier
CFTR NHE Ganglioside
Lipid raft
receptor
H+ H+
Internalisation
Colonisation of the Protein kinase
small intestine Endosome

cAMP
Vescicle-mediated
Activation of transport
cAMP pathway
Retrograde
Adenylate ATP trafficking
Epithelial cells cyclase Cleavage and
traslocation of Golgi
G protein
A subunit
Direct trafficking
Chemotaxis Expression of TCP Binding and
CT-A1 Endoplasmic
Bile salts and and cell activation of
ADP-ribosylation reticulum
mucus adherence cholera toxin
components

Figure 1: Mode of infection and pathogenesis of Vibrio cholerae

Vibrio cholerae enters the host through contaminated food or water, and if it survives the low pH of the acidic stomach environment, V cholera colonises the small
intestine and induces acute watery diarrhoea through the action of cholera toxin. Cholera toxin has an enzymatically active A subunit (with catalytic CT-A1 and CT-A2
polypeptides) with a pentameric B subunit. CT-AB holotoxin first binds to the GM1 ganglioside receptor present in the lipid rafts on the small intestinal epithelial
cells. Induction of curvature in the membranes facilitates entry of cholera toxin into host cells by internalisation. Binding of cholera toxin triggers endocytosis of the
holotoxin followed by transportation to the degradasome through the endoplasmic reticulum. Passage of endocytosed cholera toxin through the Golgi apparatus
depends on the cell type. In the endoplasmic reticulum, CT-A subunit dissociates from the B pentamer and transfers to the cytosol because of the action of the
endoplasmic reticulum-associated degradation (via KDEL receptors) pathway. In the cytosol, CT-A1 polypeptides refold and bind to the α-subunits of stimulatory
G proteins in the cell membrane, which leads to increased adenylate cyclase activity due to cleavage of ATP to cAMP. Stimulation of adenylate cyclase activity leads to
an increase in the intracellular concentration of cAMP, and activation of protein kinase A, which inhibits absorption of Na+ and Cl– through the NHE and
phosphorylates the CFTR Cl– channel proteins, leading to ATP-mediated efflux of Cl– and secretion of HCO3 –, Na+, K+, and H2O. Loss of Cl– prompts substantial fluid
secretion in the small intestine, minimising the resorptive ability of the large intestine, which results in severe watery diarrhoea. cAMP=cyclic AMP. CFTR=cystic
fibrosis transmembrane regulator. CT-A=cholera toxin A subunit. CT-B=cholera toxin B subunit. Cl–=chloride ions. H+=hydrogen ions. HCO3–=hydrogencarbonate ions.
H2O=water. K+=potassium ions. Na+=sodium ions. NHE=sodium–hydrogen exchanger. TCP=toxin coregulated pili.

V cholerae O1 strains isolated between 1991 and 1994
from Bangladesh showed hybrid phenotypes of classical
and El Tor strains, but genetically belonged to the El Tor
lineage.12 Consequently, these hybrid strains became
dominant among the 7PET lineage13 with several
mutations in the gene encoding the cholera toxin B
subunit, ctxB. Currently, more than ten ctxB alleles have
been identified; of these ten alleles, ctxB1 represents the
See Online for appendix classical O1 biotype, ctxB3 the El Tor biotype, and ctxB7
the recent El Tor variants.14 El Tor variants secrete higher
amounts of cholera toxin than the original El Tor, as
evidenced by in vitro and in vivo studies.15–18
Cholera pathophysiology and virulence factors
V cholerae typically enters the host through contaminated
food or beverage (figure 1). If the bacteria survive the low
pH of the stomach, they enter the small intestine where
they move towards epithelial cells by chemotaxis, and
then multiply and secrete cholera toxin. Cholera toxin has
an enzymatically active A subunit, which activates
adenylate cyclase to cause a net increase in cyclic AMP
(cAMP). The increased cAMP leads to activation of
protein kinase A, which inhibits sodium chloride
absorption resulting in an efflux of chloride ions and
secretion of hydrogencarbonate ions, sodium and
potassium ions, and water. Loss of chloride prompts
substantial fluid secretion into the small intestine,
overwhelming the resorptive capacity of the large
intestine, resulting in severe watery diarrhoea. Expression
of toxin coregulated pilus, cholera toxin, and other
virulence factors (appendix pp 1–2) are under the control
of virulence regulon ToxR. V cholerae adjusts its lifecycle
using other factors such as flagella synthesis and
expression of genes by RNA polymerase.19
V cholerae uses quorum sensing to detect signal
molecules called autoinducers, which help the pathogen
to synchronise biofilm formation, expression of
virulence, and production of secondary metabolites,
allowing the pathogen to infect the small intestine and to
survive in the presence of bile salts and reduced
oxygen.20 Several studies have highlighted the role of the
gut microbiome in shaping V cholerae infection,
colonisation, and disease severity risk.21–23 The presence
of some microbial communities, such as the genera

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Prevotella and Bifidobacterium, have been associated with
protection from cholera and also inhibit the virulence
gene expression of V cholerae.22
Clinical features
Infection with V cholerae can result in a spectrum of
disease presentations, from symptomless intestinal
colonisation, to mild or severe diarrhoea.24 The likelihood
that exposure to V cholerae results in disease depends on
the route of exposure, inoculum size, the infecting strain,
previous infection history, and other host and pathogen
attributes. The median infectious dose is on the scale of
100 000 000 organisms,25,26 although this drops to
100–10  000 when intake is accompanied by a buffer
solution, which might mimic food-borne transmission.27,28
Freshly shed V cholerae exist in a transient hyperinfectious
state, where the infectious dose might be even further
reduced.29 In cholera-endemic areas, previous cholera
infection leads to a lower likelihood of severe disease
during exposure. For example, in Bangladesh, an
estimated 2% of people infected with V cholerae developed
severe cholera.30,31 By contrast, in rural Haiti in 2011, less
than a year after cholera was first introduced into the
country, 9% of those with serological evidence of recent
infection reported severe cholera-like symptoms.32
The incubation period of cholera is usually between
half a day and 4∙5 days (median 1∙4 days),33 after which
illness typically starts suddenly, with frequent stool
passage (appendix p 4) and, often, vomiting. In the most
severe cases, stool output can be as high as 1000 mL/h in
adults and 10–20 cm³/kg per h in children.34,35 Although
fluid loss varies widely across medically attended
patients, a meta-analysis estimated a median stool
volume of 13∙5 L over the duration of hospitalisation for
adults and 368 mL/kg in children.36 Without antibiotics,
shedding of bacteria in stool typically lasts less than
5 days.37 However, even with antibiotics, some cases of
protracted shedding (eg, lasting several weeks) have
been documented.38 Systemic manifestations such as
fever are unusual.
If left untreated, cholera can lead to severe dehydration,
hypovolaemic shock, and death. Pulmonary oedema can
occur if excessive intravenous fluids are given. The
major derangements occur due to hypovolaemia and
electrolyte imbalance.39 With dehydration, haematocrit,
serum-specific gravity, and serum protein are elevated.
There could be hyponatraemia due to substantial sodium
loss in the stool.40 Serum potassium is usually normal
during the acute phase of disease, reflecting the
exchange of intracellular potassium and extracellular
hydrogen for correcting acidosis. Depending on the
degree and duration of dehydration, patients might have
elevated blood urea nitrogen, creatinine, calcium, and
magnesium concentrations.39 Although hyperglycaemia
might occur secondary to the release of epinephrine,
glucagon, and cortisol, hypoglycaemia is a more life-
threatening issue than hyperglycaemia and is especially
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Panel : Assessment of dehydration in patients with
cholera41,43
Severe dehydration
The patient has one or more of the following danger signs:
• Lethargy or lack of consciousness
• Absent or weak pulse
• Respiratory distress
Or the patient has at least two of the following signs:
• Sunken eyes
• Inability to drink or poor drinking ability
• Skin pinch that goes back very slowly (>2 s)
Some dehydration
The patient has no danger signs and has at least two of the
following signs:
• Irritability or restlessness
• Sunken eyes
• Rapid pulse
• Strong thirst (drinks eagerly)
• Skin pinch that goes back slowly (>2 s)
No dehydration
The patient is:
• Awake and alert
The patient has:
• Normal pulse
• Normal thirst
• No sunken eyes
• Normal skin pinch
important in young children (younger than 5 years) and
malnourished individuals. Point-of-care glucose testing
is useful for detecting hypoglycaemia, particularly in
patients with altered mental status, as this symptom
could be due to volume loss or hypoglycaemia.
Children with severe acute malnutrition, older
individuals, and individuals with chronic conditions
(eg, congestive heart failure, chronic kidney disease,
diabetes, and hypertension) are especially susceptible to
complications.41 Although pregnancy does not appear to
increase the risk of cholera, pregnant women with
cholera are at increased risk of having miscarriages,
premature deliveries, and stillbirths.42 A study in Haiti
estimated the risk of intrauterine fetal death due to
placental ischaemia to be nine times higher in
individuals with severe dehydration from cholera than
in individuals with mild dehydration.42
Management
Fluid management is the cornerstone of cholera
treatment and is based on an assessment of dehydration
status (panel).41,43 Severe dehydration should be urgently
managed in a hospital or a cholera treatment centre.
Intravenous fluids—Ringer’s lactate, or if not available,
normal saline—should be given immediately to replace
the fluid deficit (appendix p 2).41,43,39 For the initial bolus,
 Seminar
more than one intravenous line might be necessary.
When intravenous rehydration is not possible, and the
patient cannot drink, oral rehydration solution (ORS)
could be given by nasogastric tube, but this treatment
should not be given to patients who are vomiting.
Femoral vein or intraosseous access could be used, if
trained staff and necessary supplies are available. The
fluids lost by the patient (eg, stool and vomitus) should
be measured and the equivalent volumes added to the
amount used for initial treatment. Patients should be
encouraged to drink ORS once they are fully conscious
and not vomiting. Management in patients with some
and no dehydration is based on oral rehydration
(appendix p 4).41,43
The standard ORS formulation (appendix p 2) is a
glucose-based solution, but rice-based solutions are
also effective in alleviating dehydration and reducing
the volume of stool loss and the duration of diarrhoea.44–46
Use of cholera cots in health facilities allows the
measurement of stool output and better containment of
infectious faecal material. If such cots are not
available, ongoing losses can be estimated as 50–100 mL
after each loose stool in children younger than
2 years, 100–200 mL in children aged 2–9 years,41 and
10–20 mL/kg in patients older than 10 years.39
Antibiotics are indicated for severe cases, pregnant
women, and for individuals with severe acute mal­
nutrition and chronic health conditions, regardless of the
degree of dehydration.41,43 A review of clinical trials found
that antimicrobial therapy shortens diarrhoea duration
by about a day, reduces the total stool volume by 50%,
reduces the amount of rehydration fluids required
by 40%, and reduces the mean duration of faecal
excretion of bacteria by almost 3 days.36,47 When antibiotics
are indicated, they should be given as soon as the
patient is able to take oral medications and should
be guided by local antimicrobial resistance patterns
(appendix p 3). Although antibiotics are typically only
indicated for severe cases of cholera, research is needed
to understand the potential effects of treating mild and
moderate cases with antibiotics both on individual
outcomes and overall community transmission.
Zinc supplementation at 20 mg per day for 10 days is
recommended for children aged between 6 months and
5 years with acute watery diarrhoea, including cholera, to
reduce subsequent mortality and further episodes of
diarrhoea.48 Childhood malnutrition is often an important
problem in areas where cholera tends to occur. Mal­
nourishment and deprivation of micronutrients leads
to lethargy and more severe illness, contributing to
increased mortality. Breastfeeding should be continued.
For children on food, feeding should be started as soon as
the patient is able to eat, which is usually within a few
hours of beginning treatment.49
Malnourished children with cholera are more likely
to develop complications and should be managed in
a hospital or a cholera treatment centre. Although
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Rehydration Solution for Malnutrition (ResOMal) is a
specially formulated ORS used to treat diarrhoea in
severely malnourished children, it should not be used
when cholera is suspected or when there is profuse
watery diarrhoea because of its low sodium content.41
Compared with standard ORS, ResOMal has higher
glucose and potassium, and lower sodium and chloride.
For severe dehydration requiring intravenous therapy,
rehydration guidelines for malnourished children should
be followed.50 These children are at risk of overhydration
and must be closely monitored.
In pregnant patients with cholera, management
should focus on effective rehydration and obstetrical
monitoring to maintain an adequate systolic blood
pressure generally above 90 mmHg. Saving the pregnant
patient’s life and ensuring adequate uterine blood flow
will help ensure the viability of the fetus. Since cholera
can cause onset of premature labour, cholera treatment
centres need to prepare for such deliveries.42 Patients
with co-infections such as malaria, HIV, and acute
respiratory infections, or with comorbidities including
obesity, severe anaemia, cardiovascular disease, diabetes,
and renal failure require special attention and closer
monitoring.43
Laboratory diagnosis
Although the detection of V cholerae in the stool of an
individual suspected to have cholera is rarely needed to
provide appropriate clinical care, laboratory confirmation
is important for outbreak response and disease
surveillance. The classic method for cholera confirmation
is culture followed by slide agglutination to confirm
serogroup or serotype.51 Although PCR is more sensitive,
it has not been used often outside of research laboratories,
partly due to the scarcity of widely agreed upon standard
primers and protocols.
All widely used rapid diagnostic tests (RDTs) for
cholera are antibody-based immunochromatographic
assays, used either directly on fresh stool or on alkaline
peptone water-enriched (for 4–6 h) stool and rectal
swabs.52 Pooled sensitivity of contemporary RDTs is
91% and specificity is 80% when done directly on stool,
and sensitivity is 89% and specificity 98% with alkaline
peptone water enrichment.53 The most commonly used
RDTs in cholera-endemic areas detect both O1 and O139
V cholerae. False positives from the O139 line on these
bivalent tests have been reported as one source of
reduced test performance. Given that serogroup O1
predominates globally, O1-only tests might lead to fewer
false positives than bivalent tests (O1 and O139) and
improved test specificity.54,55 The sensitivity of cholera
RDTs, like culture, can be reduced by sample handling
conditions, the presence of lytic bacteriophages in the
stool, and previous antibiotic use.51,56 Considering their
utility in outbreak response, surveillance, and research in
low-resource settings, RDTs have been included in
WHO’s cholera investigation kit but there are currently

no global recommendations on their systematic use.57
Once an outbreak has been declared, the use of RDTs as
part of clinical triage would not be likely to provide any
benefit for clinical care of that specific patient.
Whole-genome sequencing has largely replaced other
molecular typing methods (eg, ribotyping) over the past
decade, although multiple-locus tandem repeat analysis
continues to be used to understand diversity in strains
during specific outbreaks. Whole genome sequencing
has been used in investigating the evolution of V cholerae,
its spread, transmission, and gene acquisition or loss,
allowing for a more refined view of its population
structure and global circulation patterns.
Antimicrobial resistance
Since the early 1990s, V cholerae has gained resistance to
several antimicrobials such as strepto­mycin, chloram­
phenicol, furazolidone, and co-trimoxazole.58 These anti­
microbials were replaced by tetracycl­ines (ie, tetra­cycline
and doxycycline), fluoroquino­ lones (ie, ciprofloxacin
and nor­floxacin), and macrolides (ie, erythromycin and
azithromycin) for the treatment of cholera.58 Given that
antimicrobial resistance patterns of V cholerae vary in
time and space, antibiotic susceptibility testing of
representative V cholerae isolates is recommended to
develop an empirical treatment policy.41
Antimicrobial resistance in V cholerae is associated with
genetic modifications such as mutations of chromosomal
regions or acquisition of resistance-encoding genes from
other organisms through mobile genetic elements.
Acquisition of resistance-encoding genes could occur
via conjugation, transformation, or transduction with
transposons conferring resistance to co-trimoxazole,
streptomycin, and chloramphenicol via integrons and
resistance to tetracycline, penicillins, cephalosporins, and
monobactams by plasmid transfer. In addition, cell wall
damage promotes high level of resistance to β-lactam
antibiotics.59 Multidrug-resistant V cholerae might
carry plasmid-mediated transfer­ rable genes conferring
resistance to fluoroquinolones, aminoglycosides, and
chloramphenicol.60
During the 1970s, the first multidrug-resistant
V cholerae O1 that showed resistance against tetra­
cycline, streptomycin, and chloramphenicol was
reported in Tanzania and attributed to the presence of a
mega­plasmid belonging to an unstable incompatibility
complex C, in the context of extensive therapeutic and
prophylactic use of tetracycline.61,44 Currently, most
strains are, and have been, sensitive to tetracycline, and
doxycycline is typically the drug of choice unless local
resistance has been documen­ ted. Although 7PET
lineage strains are gener­ally susceptible to extended-
spectrum cephalosporins, V cholerae O1 strains iso­lated
in Zimbabwe during 2018–19 were resist­ant to several
antimicrobials, including ciprofloxacin and ceftriaxone.62
Concerningly, the emergence of azithromycin resistance
has been reported in China, Bangladesh, and India.63-65
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Cholera immunology and susceptibility
Human challenge and rechallenge studies in North
American volunteers,66 and data from Bangladesh,
illustrate high levels of protection against disease (and to
a lesser extent infection and shedding) for at least 3 years
after infection with a homologous serogroup. Although
longer-term data on protection from natural infection are
scant, protection conferred by killed whole-cell cholera
vaccination could last for at least 5 years.67 Protection is
serogroup specific and cross protection between O1
serotypes (Ogawa and Inaba) appears to be incomplete
and asymmetric.66,68
Innate immunity seems to play an important role in
mediating the organism at the mucosal surface and in
facilitating the development of an adaptive immune
response.69–71 V cholerae infections do not lead to clinical
inflammation, like invasive bacterial pathogens do
(eg, Shigella), but a broad inflammatory response is
generated in the gut, including an influx of macrophages,
neutrophils, and other lymphocytes and the production of
innate effector molecules.70,72 Key biological risk factors
for cholera infection and disease include blood type O
and achlorhydria.73,74
The adaptive human immune response is mainly
directed against the V cholerae lipopolysaccharide
O-antigen and the cholera toxin.75 Antibodies against
lipo­polysaccharide (or the O-antigen) are thought to
protect against cholera by inhibiting intestinal
colonisation and motility of V cholerae,76,77 and those
against cholera toxin inhibit toxin receptor binding.78
Immune responses to cholera toxin alone do not appear
to confer protection.79 Serum vibriocidal antibodies, the
most commonly used assay in vaccine evaluations and
seroepidemio­logical studies,80,81 are associated with
protection and are an indirect marker for immune
responses at the mucosal surface.79,82 Although vibriocidal
titres correlate with susceptibility to the disease and
infection,82 there is no agreed-upon titre value above
which individuals are considered immune or recently
infected. Commonly, a vibriocidal rise in paired serum
samples that is four times as high as the initial
titre is considered seroconversion.83 Serum antibodies
tend to decay to baseline concentrations within 18 months
after infection.80,84 Plasma and memory B cells targeting
the V cholerae liposaccharide, serum IgA targeting
liposaccharide and the cholera toxin B subunit, and
faecal IgA targeting liposaccharide have all been
associated with protection.84–86 Emerging evidence
suggests that T cells play a role in inducing B-cell-
mediated immunity.87
Burden of disease
To date, global burden estimates are primarily based on
suspected case reports (in general, acute water diarrhoea
without specific confirmation of V cholerae41) and large
extrapolations of data across countries and continents.
One commonly used estimate of the global burden
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Cholera cases reported
to WHO (2015–19)
0–49
50–499
500–4999
5000–24 999
25 000–199 999
1 000 000–2 300 000
NA
Figure 2: Geographical distribution of the number of cholera cases reported to WHO, 2015–19
NA=not applicable (ie, no reports to WHO).
suggests that 2·9 million cases and 95 000 deaths occur
annually in cholera-endemic areas, although this
estimate is based on extrapolations of incidence from
three sentinel surveillance sites (Kolkata, India; Jakarta,
Indonesia; and Mozambique).88 Surveillance in these
three sentinel sites from 2001 to 2005 showed an
estimated incidence of cholera (diagnosed at a health
facility) of 0·5–4·0 per 1000 population per year, with the
greatest burden in children younger than 5 years.89 In
Bangladesh, the estimated incidence of severe cholera
in 2010 from six surveillance hospitals ranged
from 0·3 to 4·9 per 1000 population.90 Surveillance in
several African sites from 2011 to 2013 found an overall
annual incidence of cholera (confirmed at a medical
facility) of 0·03 cases per 1000 population, which
increased to two cases per 1000 during large epidemics.91
From 2017 to 2019, 99 countries reported at least one
cholera case with local transmission to WHO, totalling
more than 2∙6 million cases and over 10 000 deaths,
with the majority of deaths and cases reported in Africa
and the Middle East (figure 2).92,93 Notably under-
represented in the reports are countries of the Indian
subcontinent, where cholera is known to be endemic. A
nationally representative serosurvey from Bangladesh
suggested that close to one in six individuals were
infected by V cholerae O1 in 2015, although only a small
proportion of these infections resulted in severe
disease.94 In India, reports of cholera outbreaks are
widespread and common.95 In sub-Saharan Africa,
more than 140  000 suspected cases per year were
estimated between 2010 and 2016, although the
number of true cases that occurred is unclear.
Inadequate surveillance and reporting, poor specificity
of clinical case definitions, potential undercounting
of clinical diseases, insufficient systematic laboratory
confirmation, and fear of the effect on trade and
tourism have hampered efforts to understand the true
global burden of cholera.
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Like cholera cases, the true mortality burden of cholera
is unclear. Reported cholera deaths typically include only
individuals who die in health facilities and do not include
deaths that occur at home or in transit to a health facility.96,97
Within cholera treatment centres, high case-fatality ratios
have often been reported during the start of outbreaks,
when medical staff are overwhelmed or have not had
recent training in standard cholera management
protocols.98–100 Evidence from large epidemics in Haiti96 and
Tanzania101 suggest that a large proportion of deaths from
cholera go unreported. Across six countries
in sub-Saharan Africa from 2010 to 2013, case-fatality
ratios varied widely from 0% to 10%, with a median
of 1%.91
Local and global transmission of V cholerae
V cholerae is transmitted through the faecal–oral route,
through food, water, fomites,102 and direct contact with
infected individuals. Transmission within households is
common and is associated with sharing of contamin­ated
stored water and food, as suggested by several observational
studies.24,103 Spatiotemporal clustering patterns of cases
across multiple settings have further established the
importance of transmission both within households
and between neighbouring households.104,105 V cholerae
transmission has been conceptualised as a mix
of two primary routes distinguished by the lag
between shedding and subsequent infections. In the
environmentally mediated transmission route, bacteria
are shed into the local environment (eg, water distribution
systems and stored water) and subsequent infections
occur with some delay because vibrio can survive for a
long time outside the human gut. The second, direct,
transmission route is a result of an exposure to shed
bacteria without a substantial time lag in the local
environment (eg, through unwashed hands in food
preparation). The mix of direct and environmentally
mediated transmission can shape the speed and size of

cholera outbreaks. Estimates of the cholera reproductive
number typically range from 1 to 3,106–109 with a mean serial
interval (ie, time between symptom onset in successive
cases) of 3–4 days.106
Phylogenetic analyses have expanded current
understanding of the global circulation of 7PET lineages.
These analyses have suggested that areas around the Bay
of Bengal act as a global source for 7PET diversity with
regular exports via human travel sparking local,
sometimes long-lived, regional outbreaks.110–112 In Africa,
which has a substantial cholera burden, 7PET has been
introduced at least 12 distinct times from south Asia,
with each introduction leading to regional epidemics and
some lasting more than 40 years.113,114 Similarly, a single
introduction of 7PET into Haiti in 2010,13 where cholera
had not been known to circulate, led to more than 8 years
of sustained transmission on the island of Hispaniola.
Work on the ecology of cholera in the 1980s and 1990s
suggested that cholera epidemics were largely modulated
by environmental factors such as humidity, rainfall, and
sea surface temperature.115 Although environmental
factors might play a part in some locations (eg, areas
around the Ganges Delta), genomic and epidemiological
studies suggest that human-to-human spread
(eg, through travel) is much more likely to be responsible
for large-scale 7PET dissemination than the climate.114
The strength and direction of the associations of climate
with cholera vary widely over space and time. For
example, areas of sub-Saharan Africa have increased
cholera incidence rates during El Niño periods, whereas
other areas have decreased cholera incidence rates
during El Niño periods, compared to the expected
incidence rates of cholera.116 Precipitation has been
shown to increase the transmission potential in
outbreaks in Yemen98 and Haiti,117 although droughts and
flood have also been associated with cholera outbreaks.118
Defining the geographical regions where weather and
climate variables could explain important variability in
cholera incidence and occurrence are important areas for
research.
Prevention and control
The WHO-backed Global Roadmap to 2030, which
proposes to end cholera by 2030, suggests a three-
pronged approach: first, the early detection of cholera
cases and quick response to contain outbreaks; second, a
targeted multisectoral approach to prevent cholera
recurrence; and third, an effective and coordinated
mechanism for technical support, advocacy, resource
mobilisation, and partnership at local and global levels.41
This task requires engaging communities, improving
early warning surveillance, building laboratory capacities,
strengthening health systems, and ensuring ready
supplies of logistics. Major steps in implementing the
global roadmap include a targeted multisectoral approach
to identify and focus on cholera hotspots, which are
small geographical regions that are either heavily affected
www.thelancet.com Vol 399 April 9, 2022 1435
Seminar
by cholera or play an important role in transmission.56
The two primary cholera prevention and control
approaches are the use of OCVs, which provide nearly
immediate but temporary protection, and improving
water, sanitation, and hygiene (WASH), which in some
cases is not immediately achievable but can lead to
sustained reductions in transmission of V cholerae (and
other water-related pathogens).
Three types of OCV are available: killed whole-cell
vaccines (Shanchol, Shantha Biotechnics, Hyderabad,
India; and Euvichol, Eubiologics, Gangwon-do, South
Korea), a killed whole cell vaccine with a recombinant B
subunit (Dukoral, Valneva, Sweden), and a live
attenuated vaccine (Vaxchora, Emergent Biosolutions,
Rockville, MA, USA; table).41,67,119–124 Vaxchora and Dukoral
are primarily used by people travelling to cholera-
endemic areas as these vaccines are relatively expensive.
Dukoral must be administered with a buffer solution,
and Vaxchora requires dilution in non-chlorinated water
and should be used only where medical waste can be
discarded safely. Shanchol and Euvichol, which have
similar formu­lations and are WHO prequalified (table),
are the two vaccines used in outbreaks and cholera-
endemic countries, although these vaccines are less
effective in young children (ie, younger than 5 years)
than in older children and adults (similar to Dukoral).125
Schanchol and Euvichol are intended as two-dose
vaccines, with the second dose taken 2 weeks after the
first, which could be less optimal than longer interdose
periods.126,127
In 2012, following large cholera outbreaks in
Zimbabwe and Haiti, an OCV stockpile was created to
break the cycle of poor supply and demand.128 OCV
doses for outbreak response and humanitarian crises
are managed by the International Coordinating Group
(comprising representatives from Médecins Sans
Frontières, the International Federation of Red Cross
and Red Crescent Societies, UNICEF, and WHO),
whereas the GTFCC support Gavi, the Vaccine Alliance,
in allocating doses for cholera-endemic areas.129
Although the number of OCV doses deployed by the
stockpile has increased from about 2 million per year
in 2013–14, to 25 million in 2021 (less in 2020 due to the
COVID-19 pandemic), demand continues to outstrip
supply.130 Only about half of the 25 million doses
requested from the OCV stockpile from 2013 to 2017
could be allocated and shipped to countries for mass
vaccinations.131
Evidence suggests that the risk of cholera among
neighbours of medically attended patients with cholera
is much higher than others in the general population
within the first week after a patient presents with
cholera.103–105 Focused interventions around the
households of medically attended patients with cholera,
called case area targeted interventions (CATIs), have
been proposed as an efficient way of interrupting
transmission.132 CATIs that include WASH interventions
 Seminar

Type Composition Recommended dose or regimen Recommended age of Protective efficacy

Dukoral (Valneva, WC-rBS: killed whole-cell
Sweden) monovalent (O1) vaccine with a
recombinant cholera toxin B
subunit
Shanchol (Shantha BivWC: killed whole-cell bivalent
Biotechnics, India) (O1 and O139) vaccine without
the cholera toxin B subunit
Euvichol or Euvichol- BivWC: killed whole-cell bivalent
Plus (EuBiologics, (O1 and O139) vaccine without
South Korea) cholera toxin B subunit
Vaxchora (Emergent CVD 103-HgR: live attenuated
BioSolutions, USA) vaccine
V cholerae=Vibrio cholerae.
V cholerae O1 Inaba classical biotype;
V cholerae O1 Inaba El Tor biotype;
V cholerae O1 Ogawa classical
biotype; recombinant cholera toxin
B subunit 1 mg
V cholerae O1 Inaba El Tor strain Phil
6973; V cholerae O1 Ogawa classical
strain Cairo 50; V cholerae O1 Inaba
classical strain Cairo 48; V cholerae
O139 strain 4260B
V cholerae O1 Inaba Cairo 48 classical Two doses at an interval of
biotype; V cholerae O1 Inaba Phil
6973 El Tor biotype; V cholerae O1
Ogawa Cairo 50 classical biotype;
V cholerae O139 strain 4260B
V cholerae O1 Inaba classical biotype
vaccination
Two doses in adults and children
aged >6 years, three doses for
children aged ≤6 years; >1 week
before potential exposure
Two doses at an interval of
2 weeks
2 weeks
Single dose at ≥10 days before
potential exposure
Adults, and children Randomised, placebo-controlled
aged ≥2 years trials of earlier versions of Dukoral
in Bangladesh showed a two-
dose protective efficacy against
medically attended cholera of
74% at 1 year119 and 64% at
3 years120
Adults, and children A randomised, placebo-controlled
aged ≥1 year trial in India showed that a two-
dose regimen confers 67%
protective efficacy against
medically attended cholera within
2 years of vaccination,121 66% at
3 years,122 and 65% at 5 years67
Adults, and children No published clinical efficacy
aged ≥1 year data; licensed on the basis of
immunogenicity data given its
bioequivalence to Shanchol123,124
Adults, and children Human challenge study in North
aged ≥6 years American volunteers showed
90% efficacy against moderate to
severe cholera 10 days after
challenge, and 80% efficacy
90 days after challenge41

Table: Summary of characteristics of available oral cholera vaccines

have been shown to reduce the duration of outbreaks at
a community scale in Haiti,133 and a modelling study134
has suggested large effects if OCVs are included in these
interventions.
It is widely accepted that major infrastructure im­
provements, including piped water and sewage systems,
led to the elimination of cholera and reductions in the
burden of other pathogens in North America and Europe.
The global public health community must commit to
these improvements and do more to accomplish these
goals in lower-income countries. As called for in the UN
Sustainable Development Goals, universal safe water and
sanitation are urgently needed in many areas of the world
to reduce cholera, among numerous other benefits.
Unfortunately, progress over the past two decades has
been slow and must be accelerated.135 Even with serious
commitments to close these gaps, it will take time to serve
the 1∙6 billion people without safe water at home, and the
2∙8 billion people without safe sanitation. While waiting
for sustainable water and sanitation infrastructure, there
are several smaller-scale WASH interventions that have
been used to reduce cholera risk. These include point-of-
use water treatment, safe storage of water systems using
simple vessels with lids and taps, provision of sanitation
facilities (including latrines and flush toilets) to reduce
exposure to faeces, and behaviour change campaigns
targeted at increasing handwashing and promoting safe
funeral practices.136 Evidence of sustainable reductions in
cholera incidence from these smaller-scale interventions
is a crucial area for future research.137–140
The future of cholera
Despite the long history of cholera in clinical and
epidemiological research, billions of people remain at
risk of this preventable disease. Over the past decade, a
surge in the global commitment to fighting cholera has
occurred through the development of the Global
Roadmap to 2030, numerous countries developing
national cholera plans, and the wider availability of
cholera vaccines. Although elimination of cholera might
be the goal, it remains unclear whether this goal is
realistic in the coming decade. After more than 8 years of
sustained cholera transmission in Haiti, which resulted
in nearly 10 000 deaths, from early 2019 to the time of
writing (December, 2021), no cholera cases have been
reported from Haiti (or the island of Hispaniola), despite
surveillance efforts to detect and confirm suspected
cases.140 This apparent disappearance of cholera from
Haiti provides hope that even while there is work towards
universal access to safe water and sanitation, large
reductions in cholera burden might be achievable. As
countries try to eliminate cholera, drastic improvements
in surveillance systems, including the development of
diagnostic assays adapted for use in low-resource settings,
are needed to better understand local and regional cholera
dynamics and to track changes in cholera incidence.
Although the past decade has seen a dramatic rise in
the use of OCVs, we have yet to see cholera vaccines
integrated into routine immunisation plans. Efforts
are underway to develop improved vaccines, scale up
production of current-generation vaccines, and to develop

1436 www.thelancet.com Vol 399 April 9, 2022


improved vaccination guidance. Ultimately, the long-term
and most sustainable route to the prevention of cholera
and other enteric diseases is through improved WASH.
Given the efficacy of rehydration therapy, investments in
primary health-care systems and in­ creasing access to
health care could have the greatest potential to bring
cholera mortality to zero.
Contributors
SD coordinated the overall preparation of this paper and critically
reviewed it. SK, JD, and ASA wrote the initial drafts of the introduction,
clinical features, management, and prevention and control sections.
TR and SD wrote the initial draft of the sections about bacteriology,
molecular epidemiology, pathophysiology, virulence factors, and
diagnosis and antimicrobial resistance. ASA and TR wrote
the initial draft of the section about immune response. ASA wrote the
initial draft of the section about epidemiology and burden. All authors
reviewed, edited, and approved the final version of the manuscript.
Declaration of interests
ASA is supported by grants from the National Institutes of Health (R01
AI135115) and grants from the Bill & Melinda Gates Foundation (INV-
021879 and INV-002667). ASA and SD serve on the Global Task Force for
Cholera Control working groups for Oral Cholera Vaccines and
Surveillance and Epidemiology of Cholera. All other authors declare no
competing interests.
Acknowledgments
We thank Dharanidharan Ramamurthy at the Medical Biotechnology
and Immunotherapy Research Unit, Faculty of Health Sciences,
University of Cape Town, South Africa, for the preparation of figures
using BioRender.
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