Cholera
A bacterial intestinal infection spread through contaminated food or water that can cause sudden watery diarrhea, severe dehydration, shock, and death without rapid treatment.
What causes Cholera?
Cholera is caused by toxin-producing Vibrio cholerae bacteria, mainly serogroups O1 and O139. People become infected by consuming water or food contaminated with feces, especially where sanitation and drinking-water treatment are inadequate.
Symptoms and what to notice
Most infections cause no symptoms or mild illness. Severe cholera produces sudden, profuse watery diarrhea, vomiting, thirst, leg cramps, weakness, reduced urination, low blood pressure, and shock from rapid fluid and electrolyte loss.
How long can it last?
Symptoms can begin 12 hours to 5 days after exposure. With prompt rehydration, diarrhea and vomiting often improve within several days, although weakness can persist and bacteria may be shed in stool after symptoms improve.
How serious is Cholera?
About 1 in 10 infected people develops severe symptoms. Untreated fluid loss can cause shock, kidney failure, electrolyte abnormalities, seizures, or death within hours. Timely rehydration allows more than 99% of patients to survive.
Treatment and management
Begin oral rehydration solution immediately and seek medical care. Severe dehydration requires rapid intravenous fluids plus ORS. Selected severely ill patients receive antibiotics, and children ages 6 months through 5 years may receive zinc. Treatment should not wait for laboratory confirmation.
Vaccine: who and when?
Product: VAXCHORA, the only U.S.-approved cholera vaccine. It is a live oral vaccine given as one dose to eligible travelers ages 2 through 64 at least 10 days before potential exposure to Vibrio cholerae O1. It has not been shown to protect against O139 or other non-O1 serogroups, and revaccination has not been established. Dukoral, Euvichol-Plus, and Euvichol-S are WHO-prequalified products used outside the United States but are not available in the U.S.
Cost note: VAXCHORA price, travel-clinic consultation, preparation, and administration fees vary, and travel vaccines are not always covered by insurance. Ask the provider for a complete current estimate.
Trusted source
Patient cost varies by insurance, provider, location, and eligibility. Coverage and public-health access differ, so listed prices are examples rather than guaranteed patient prices. This page is for general education and does not replace individualized medical advice, diagnosis, vaccination assessment, or treatment.
Cholera: Causes, Symptoms, Dehydration, Treatment, Prevention, and Vaccine Information
Cholera is an intestinal infection that can cause sudden, profuse watery diarrhea and life-threatening dehydration. It is caused by toxigenic strains of the bacterium Vibrio cholerae and is usually acquired by consuming contaminated water or food. The disease is closely associated with unsafe drinking water, inadequate sanitation, poor hygiene, population displacement, conflict, natural disasters, and breakdowns in public-health infrastructure.
Most infected people have no symptoms or only mild illness. About one in ten develops severe symptoms, according to CDC. In a severe case, fluid and electrolytes can be lost so quickly that shock and death may occur within hours. Cholera is also highly treatable: prompt oral rehydration solution, intravenous fluids when needed, and appropriate medical care allow more than 99% of patients to survive.
Cholera is rare in the United States but remains a risk in many parts of the world. U.S. travelers may be exposed when visiting areas with active transmission or unsafe water and sanitation. VAXCHORA is the only cholera vaccine approved in the United States. It is a single-dose live oral vaccine for eligible travelers ages 2 through 64 and must be given at least 10 days before potential exposure.
Quick Facts
- Cause: Toxin-producing Vibrio cholerae, mainly serogroups O1 and O139.
- Spread: Contaminated water or food, usually through fecal contamination.
- Incubation period: Symptoms can begin 12 hours to 5 days after infection.
- Typical symptoms: Acute watery diarrhea, vomiting, thirst, weakness, and leg cramps.
- Severe danger: Rapid fluid and electrolyte loss can cause severe dehydration, shock, kidney failure, and death.
- Most important treatment: Immediate oral rehydration solution; severely dehydrated patients need rapid intravenous fluids.
- Antibiotics: Used for selected patients, especially severe illness, alongside rehydration.
- U.S. vaccine: VAXCHORA, a single oral dose for eligible travelers ages 2 through 64.
- Timing: Give VAXCHORA at least 10 days before potential exposure.
What Causes Cholera?
Cholera is caused by Vibrio cholerae, a curved, gram-negative bacterium that can live in aquatic environments. Many strains do not cause epidemic cholera. The strains responsible for outbreaks produce cholera toxin and usually belong to serogroup O1 or O139. O1 has caused all recent major outbreaks; O139 has caused outbreaks in Asia in the past and now appears mainly in sporadic cases.
After a susceptible person swallows enough bacteria, the organisms can survive passage through the stomach and colonize the small intestine. Cholera toxin disrupts the movement of salt and water across the intestinal lining. Large amounts of chloride and water enter the intestine, producing the characteristic watery diarrhea.
The bacteria do not need to invade deeply into intestinal tissue to cause severe illness. The major threat is the enormous volume of fluid and electrolytes that can be lost through stool and vomiting.
How Cholera Spreads
People usually acquire cholera by drinking water or eating food contaminated with small amounts of feces from an infected person. The disease can spread rapidly when sewage and drinking-water systems are not adequately separated or treated.
Common exposure settings include:
- Drinking untreated water
- Using unsafe water to make ice or prepare food
- Eating food handled with contaminated hands
- Eating raw or undercooked seafood from contaminated coastal or brackish water
- Eating raw produce washed with unsafe water
- Living in crowded settings with inadequate toilets and handwashing facilities
- Disasters, conflicts, or displacement that disrupt water and sanitation systems
Casual person-to-person spread is unlikely. Cholera is not normally transmitted by coughing, sneezing, hugging, or briefly sharing a room. Household transmission can nevertheless occur if bacteria from stool contaminate hands, food, water, surfaces, or eating utensils.
Where Cholera Occurs
Cholera remains endemic or causes outbreaks in parts of Africa, Asia, the Middle East, the Caribbean, and other regions where safe water and sanitation are limited. Risk can change quickly after floods, cyclones, earthquakes, conflict, or displacement.
The seventh cholera pandemic began in South Asia in 1961 and continues today. WHO estimates 1.3 to 4 million illnesses and 21,000 to 143,000 deaths globally each year. Reported numbers are lower than the estimated burden because many illnesses are not diagnosed or reported.
Cholera is rare in the United States. Most U.S. cases are associated with international travel or contaminated seafood. Local Vibrio bacteria can exist in coastal waters, but epidemic cholera does not normally occur where drinking water, sewage treatment, food safety, and public-health systems function reliably.
Incubation Period
Symptoms may begin from about 12 hours to 5 days after exposure. This short incubation period helps cholera spread rapidly during outbreaks.
An infected person without symptoms can still shed bacteria in stool. WHO reports that bacteria may be present in feces for 1 to 10 days after infection. Safe disposal of feces, handwashing, disinfection, and protection of food and water are therefore important even when illness is mild.
Symptoms of Cholera
Most infected people do not become sick. Others have mild or moderate diarrhea that may be difficult to distinguish from many other intestinal infections. About one in ten develops severe disease.
Possible symptoms include:
- Sudden watery diarrhea
- Large-volume, pale stool sometimes described as rice-water stool
- Vomiting
- Intense thirst
- Leg or muscle cramps
- Weakness and restlessness
- Dry mouth and reduced tears
- Reduced urination
- Sunken eyes
- Rapid heart rate
- Low blood pressure
- Cold or clammy skin
Fever is often absent or mild. Blood in the stool is not typical of cholera and may suggest another cause of diarrhea.
Why Cholera Can Become Dangerous So Quickly
Severe cholera can produce fluid losses of many liters per day. Water loss is accompanied by sodium, chloride, potassium, and bicarbonate loss. Without replacement, the circulating blood volume falls, tissues receive less oxygen, and organs begin to fail.
Signs of severe dehydration include:
- Extreme thirst
- Little or no urine
- Marked weakness or inability to stand
- Rapid or weak pulse
- Low blood pressure
- Sunken eyes
- Poor skin elasticity
- Confusion, unusual sleepiness, or unconsciousness
- Rapid breathing
- Cold hands and feet
Complications can include hypovolemic shock, acute kidney injury, severe electrolyte disturbances, acidosis, low blood sugar in children, seizures, and death. A person with profuse watery diarrhea or signs of dehydration needs immediate treatment.
How Long Does Cholera Last?
With prompt rehydration, vomiting and diarrhea often improve over several days. Mild illness may resolve without complications, while severe illness requires close monitoring until fluid and electrolyte losses stop and normal drinking, eating, and urination resume.
The bacteria may continue to be shed in stool for days after symptoms improve. Public-health or healthcare instructions about hygiene, work, food handling, childcare, travel, and follow-up testing should be followed.
Recovery time depends on illness severity, age, nutrition, underlying conditions, treatment speed, and whether complications occurred. Weakness can continue after the intestinal symptoms end, particularly after severe dehydration.
Who Is at Greater Risk?
Exposure risk is highest for people living in or visiting places where safe drinking water, toilets, sewage treatment, and handwashing supplies are inadequate. Humanitarian emergencies can create especially hazardous conditions.
The likelihood of severe illness can be higher among:
- People with reduced stomach acid
- People with blood type O
- Malnourished children
- People with limited access to rapid rehydration treatment
- People with significant chronic illness
- Pregnant people who become severely dehydrated
Travelers staying in standard tourist accommodations and following food and water precautions generally have a low risk, even in countries where cholera occurs. Risk increases for people visiting outbreak areas, remote communities, refugee settlements, or locations without reliable sanitation.
Diagnosis and Testing
The clinical priority is to assess dehydration and begin rehydration immediately. Treatment should not wait for laboratory confirmation when cholera is suspected.
Confirming a single case generally requires testing a stool sample. Culture can identify Vibrio cholerae O1 or O139, and polymerase chain reaction testing can detect relevant bacterial and toxin genes. Public-health laboratories may further characterize an isolate and assess antimicrobial susceptibility.
Rapid diagnostic tests can provide early warning during an outbreak, but positive results should be confirmed by culture or PCR because rapid tests are less specific. In the United States, cholera is nationally reportable, and isolates are sent through state health departments to CDC for additional testing and subtyping.
Treatment: Start Rehydration Immediately
Rehydration is the central treatment for cholera. If cholera is suspected, begin oral rehydration solution and seek medical attention immediately. CDC states that with timely rehydration, more than 99% of patients survive.
Oral Rehydration Solution
Oral rehydration solution, or ORS, contains a balanced amount of glucose and salts that helps the intestine absorb water. It is different from plain water, juice, soda, or a typical sports drink.
Commercial ORS packets should be mixed exactly as directed using safe water. Too little water can make the solution dangerously concentrated; too much water can make it ineffective. Continue offering ORS during transport to a healthcare facility unless the patient cannot safely drink.
If an ORS packet is unavailable, safe water or broth is preferable to no fluid while medical help is obtained. Avoid high-sugar drinks such as soda, juice, or many sports drinks because they can worsen diarrhea.
Babies with watery diarrhea should continue receiving breast milk or formula while urgent medical care is arranged. Feeding should generally continue as soon as tolerated.
Intravenous Fluids
People with severe dehydration, shock, persistent vomiting, altered consciousness, or inability to drink need urgent intravenous fluids. Ringer’s lactate is commonly preferred in cholera treatment settings. IV therapy is adjusted according to body weight, pulse, blood pressure, mental status, urine output, and continuing stool losses.
ORS is added as soon as the patient can drink, even when IV fluids are still being given. Fluid needs may remain very high until diarrhea slows.
Antibiotics
Antibiotics are not a substitute for rehydration. They may be recommended for severely ill patients and selected others because they can shorten the duration and volume of diarrhea and reduce bacterial shedding.
The best antibiotic depends on local resistance patterns, age, pregnancy, allergies, and disease severity. Clinicians may use doxycycline, azithromycin, or other agents when appropriate. Unnecessary or mass preventive antibiotic use is discouraged because it does not control outbreaks and contributes to antimicrobial resistance.
Zinc for Children
CDC recommends that children ages 6 months through 5 years with suspected cholera receive zinc supplementation when available. Zinc can reduce the duration and severity of childhood diarrhea. Dosing should follow clinical or public-health guidance.
What Not to Do
- Do not delay care while waiting for a laboratory result.
- Do not use antibiotics without medical guidance.
- Do not give anti-diarrheal medicines to a severely ill person without professional advice.
- Do not rely on plain water alone when major electrolyte losses are occurring.
- Do not mix ORS with an incorrect amount of water.
- Do not prepare food for other people after handling diarrhea or vomit without thorough handwashing and sanitation.
Preventing Cholera: Safe Water
In a cholera-risk area, use bottled water with an intact seal or water that has been properly boiled, chlorinated, or filtered and disinfected. Safe water should be used for:
- Drinking
- Brushing teeth
- Preparing food and beverages
- Making ice
- Washing dishes
- Washing fruits and vegetables
- Making infant formula
If safety is uncertain, bring water to a rolling boil for at least one minute, then cool it in a clean covered container. At high elevations, public-health guidance may recommend a longer boiling time. Chemical disinfection and filtration must be performed with products and methods appropriate for the water source.
Avoid swallowing water while bathing. Keep safe drinking water in clean, covered containers and use a clean ladle or tap rather than dipping hands or cups into stored water.
Food Safety
Choose food that is thoroughly cooked and served hot. Avoid raw or undercooked seafood, especially shellfish. Peel fruits yourself and avoid raw produce that cannot be washed with safe water.
Street food can be safe when freshly cooked in front of the customer and served steaming hot, but food that sits at room temperature or is handled repeatedly poses more risk. Be cautious with ice, sauces, unpasteurized dairy products, and foods washed with untreated water.
Handwashing, Sanitation, and Cleaning
Wash hands frequently with soap and safe water, especially after using the toilet, changing diapers, caring for a sick person, cleaning diarrhea or vomit, and before preparing or eating food. If soap and safe water are not available, an alcohol-based hand sanitizer can be used temporarily, but it does not replace handwashing when hands are visibly dirty.
Use toilets or safely managed latrines. Keep feces away from water sources. Clean surfaces contaminated with diarrhea or vomit using an appropriate chlorine solution while wearing gloves. Dispose of contaminated materials safely and wash soiled clothing and bedding with detergent and safe water.
Cholera Vaccine Available in the United States
VAXCHORA is the only cholera vaccine approved for use in the United States. Its proper name is Cholera Vaccine, Live, Oral. It is manufactured by Bavarian Nordic.
FDA approves VAXCHORA for active immunization against disease caused by Vibrio cholerae serogroup O1 in people ages 2 through 64 who are traveling to cholera-affected areas.
Key details include:
- One dose taken by mouth
- Give at least 10 days before potential exposure
- Approved for ages 2 through 64
- Protects against serogroup O1
- Not proven to protect against O139 or other non-O1 serogroups
- No established recommendation for revaccination
- Not routinely recommended for most U.S. travelers
VAXCHORA is prepared and administered in a healthcare setting. The recipient should avoid eating or drinking for 60 minutes before and after taking the vaccine. The reconstituted amount is 100 mL for most recipients and 50 mL for children ages 2 through 5.
Who Should Consider VAXCHORA?
Vaccination may be considered for eligible travelers going to an area with active cholera transmission, an outbreak, unsafe water, or a humanitarian crisis with high cholera risk. The decision depends on the destination, itinerary, lodging, access to safe food and water, length of stay, activities, age, health status, and ability to receive prompt care.
Cholera vaccine does not replace food and water precautions because it is not 100% effective and does not protect against every cholera-causing serogroup or other causes of diarrhea.
Who Should Not Receive VAXCHORA?
A person with a history of a severe allergic reaction, such as anaphylaxis, to a previous cholera vaccine or a VAXCHORA component should not receive it.
VAXCHORA is a live vaccine. Safety and effectiveness have not been established in immunocompromised people, and these patients may have a reduced immune response or special safety considerations. A clinician should evaluate pregnancy, breastfeeding, immune suppression, recent medicines, recent antibiotics, and other vaccines before administration.
The vaccine strain can be shed in stool for at least seven days and might be transmitted to close contacts. Extra caution is appropriate when a recipient lives with someone who is severely immunocompromised. Careful handwashing after using the toilet and before preparing food is important.
VAXCHORA Side Effects
Common reactions reported in studies include tiredness, headache, abdominal pain, nausea or vomiting, reduced appetite, and diarrhea. Side effects are generally temporary. A severe allergic reaction is rare but requires emergency treatment.
Any concerning event after vaccination should be assessed by a healthcare professional. U.S. patients and clinicians can report adverse events to the Vaccine Adverse Event Reporting System.
Other Oral Cholera Vaccines
WHO prequalifies oral cholera vaccines used in endemic settings and outbreak campaigns. These include Dukoral, Euvichol-Plus, and Euvichol-S. They are not the same as VAXCHORA and are not available in the United States.
WHO reports that these campaign vaccines generally require two doses for full protection in adults, although one-dose Euvichol strategies have been used during global supply shortages to provide short-term protection. Product ages, schedules, buffers, availability, and national recommendations differ.
Travelers should not assume that a vaccine offered abroad follows the U.S. schedule. Advice should come from a qualified travel-medicine clinician or national public-health authority.
Vaccine Cost and Access
VAXCHORA price and administration fees vary by travel clinic, pharmacy, location, and insurance. Travel vaccines are not always covered by insurance. Ask the provider whether the quoted amount includes the vaccine, consultation, preparation, administration, and follow-up.
The vaccine may not be stocked everywhere because cholera vaccination is uncommon in routine U.S. practice. Plan a travel consultation early enough to locate the product and receive it at least 10 days before exposure.
Cholera Vaccine and Emergency Campaigns
Large outbreak-control campaigns outside the United States use WHO-prequalified oral cholera vaccines, usually through national health programs and the global stockpile. These campaigns are designed to rapidly protect communities at high risk. Vaccination is combined with clean-water provision, sanitation, hygiene, surveillance, community education, and treatment access.
Vaccination alone cannot end a cholera outbreak. The long-term solution is reliable access to safe water, basic sanitation, hygiene, and timely healthcare.
Planning Travel to an Area With Cholera
Before travel:
- Check CDC destination notices and current outbreak information.
- Schedule a travel-medicine visit early.
- Ask whether VAXCHORA is appropriate for the itinerary.
- Pack oral rehydration solution packets.
- Plan how to obtain safe water and freshly cooked food.
- Identify where emergency medical care is available.
- Bring handwashing supplies and water-treatment products when needed.
During travel, use safe water, avoid risky food, wash hands, and seek care immediately for profuse watery diarrhea. Begin ORS while arranging care.
After returning, tell a clinician about the exact destinations, travel dates, food and water exposures, and symptom onset. Stool testing and public-health reporting may be required.
Frequently Asked Questions
Is cholera contagious?
Cholera spreads through fecally contaminated water or food. Casual contact is unlikely to spread it, but contaminated hands, surfaces, food, water, or utensils can transmit the bacteria.
What does cholera diarrhea look like?
Severe cases can cause very large amounts of pale, watery stool sometimes called rice-water stool. Appearance alone cannot confirm the diagnosis.
Can cholera kill within hours?
Yes. Severe fluid loss can cause shock and death within hours when untreated. Immediate rehydration is lifesaving.
Is cholera easy to treat?
It is highly treatable when rehydration begins promptly. CDC reports that more than 99% of patients survive with timely rehydration therapy.
Can plain water treat severe cholera?
Plain water helps but does not replace the salts and glucose lost in severe diarrhea. Properly mixed ORS is preferred, and severe dehydration needs IV fluids.
Does everyone with cholera need antibiotics?
No. Rehydration is the essential treatment. Antibiotics are reserved for severely ill patients and selected others based on clinical guidance.
Is there a cholera vaccine in the United States?
Yes. VAXCHORA is the only U.S.-approved cholera vaccine. It is a live oral vaccine for eligible travelers ages 2 through 64.
How many doses of VAXCHORA are needed?
One oral dose is given at least 10 days before potential exposure. The safety and effectiveness of revaccination have not been established.
Does VAXCHORA protect against every cholera strain?
No. It is indicated against Vibrio cholerae O1 and has not been shown to protect against O139 or other non-O1 serogroups.
Can vaccination replace safe food and water practices?
No. No cholera vaccine is fully protective. Safe water, sanitation, handwashing, and food safety remain essential.
When to Seek Medical Care
Seek medical attention immediately for profuse watery diarrhea, repeated vomiting, intense thirst, little urine, weakness, dizziness, fainting, confusion, rapid heartbeat, low blood pressure, cold or clammy skin, or any sign of severe dehydration.
Start properly mixed ORS while traveling to care if the person can drink safely. Do not wait for a test result before replacing fluids.
This article is for general education and does not replace diagnosis, emergency treatment, vaccination assessment, or travel advice from a qualified healthcare professional.
Medical and vaccine information reviewed September 2026.