Cholera: worldwide risk reminder

A reminder of the risks of cholera worldwide and the importance of good food, water and personal hygiene for all travellers

Cholera is an infection spread by eating or drinking food and water contaminated with certain bacteria (Vibrio cholerae serogroups O1 and O139) in regions with poor sanitation [1, 2]. Direct spread between people can occur but is rare [2]. Cholera can be symptom free (asymptomatic) or a mild illness. However, sudden, watery diarrhoea ('rice water stools') and vomiting can occur, leading to dehydration. Some infections can cause severe disease, and in extreme cases cholera can be fatal if left untreated [1, 2].

Cholera is mainly found in Africa and Asia, but occasionally cases are reported in Europe and the Americas [1]. Cholera is not a risk in the United Kingdom (UK); the last locally acquired case was in 1893 and it is very rare in UK travellers, with most cases reported in travellers who visited Bangladesh, India or Pakistan [1, 2]. In the UK, between 2015 and 2019, an average of 15 cholera cases in returned travellers were reported each year, with a peak of 17 cases in 2018. As a result of the COVID-19 pandemic, when international travel was greatly reduced, only two imported cases were reported in 2020 and one case in 2021 [1].

An increase in cholera worldwide has been reported since 2021 [3]. In 2021, the World Health Organization (WHO) reported cholera cases in 35 countries [4], with 23 countries reporting outbreaks, mostly in Africa and the Eastern Mediterranean. This continued in 2022, with 30 countries worldwide reporting cholera cases or outbreaks, and most countries reporting higher case numbers than in previous years. There were 14 countries reporting cholera cases in 2022 (including the Dominican Republic, Haiti, Lebanon and Syria) who had not reported cases the previous year [3].

At least 24 countries in Africa and South Asia have reported cholera cases to WHO since the beginning of 2023 [5, 6]. Further geographical spread of cholera continues to be reported in the Horn of Africa, especially around the Mandera triangle, where the borders of Ethiopia, Kenya and Somalia meet [6].

There are vaccines to prevent cholera, though vaccination is only recommended for some travellers, as the risk for most UK travellers is low [1, 2].

In the UK, an oral (drink) inactivated cholera vaccine called Dukoral® is available and protects against V. cholerae serogroup O1. This vaccine is only recommended for travellers whose activities or medical history put them at increased risk, including:

• Aid workers.
• People going to areas with cholera outbreaks who have limited access to safe water and medical care.
• Those for whom vaccination is considered potentially beneficial (people who do not fit into the above groups, but are still considered at higher risk).

Vaxchora (a live, oral cholera vaccine for adults and children aged two years and older) was granted UK marketing authorisation (licensed) in 2020. The UK Joint Committee on Vaccination and Immunisation (JCVI) are in the process of reviewing the product information. Recommendations on the use of this vaccine will be published in due course.

Advice for travellers

Before you travel

Check the risk of cholera for your destination using the TravelHealthPro website: country-specific information can be found on our Country Information pages and Outbreak Surveillance section.

If you think you are at increased risk, make an appointment with your GP, a travel clinic or a pharmacy to discuss if cholera vaccine is appropriate for you.

While you are away

Follow good food and water hygiene precautions and take care with your personal hygiene.

When you return

Get medical advice if you have returned from a country with cholera and you have:

• Severe watery diarrhoea and/or vomiting.
• Signs of dehydration like feeling very thirsty and/or dark yellow and strong-smelling urine (pee).

Remember - tell the health professional treating you that you visited a country with cholera.

Advice for health professionals

Health professionals should advise travellers about their destination specific risk of cholera according to TravelHealthPro Country Information pages. Those at higher risk include those who are living or working in unsanitary conditions and drink untreated water or eat poorly cooked seafood in endemic areas.

Cholera vaccine should be offered to those at increased risk of exposure; further information is available in our cholera factsheet.

Health professionals should be alert to the possibility of cholera in a returned traveller presenting with a severe watery diarrhoeal illness. The appropriate samples (with a full clinical and travel history) should be sent to the UK Health Security Agency Gastrointestinal Bacterial Reference Unit.