Editing Cholera (section)

== Prevention ==
[[File:It doesn't hurt, but it tickles. A U.S. Navy hospital corpsman, member of a USAID military health team, inoculates a flo - NARA - 541855.jpg|thumb|upright=1.3|Preventive inoculation against cholera in 1966]]
The [[World Health Organization]] (WHO) recommends focusing on prevention, preparedness, and response to combat the spread of cholera.<ref name="who.int" /> They also stress the importance of an effective surveillance system.<ref name="who.int" /> Governments can play a role in all of these areas.

=== Water, sanitation and hygiene ===
{{Further|WASH#Health aspects}}
Although cholera may be life-threatening, prevention of the disease is normally straightforward if proper [[sanitation]] practices are followed. In [[developed countries]], due to their nearly universal advanced [[water treatment]] and sanitation practices, cholera is rare. For example, the last major outbreak of cholera in the United States occurred in 1910–1911.<ref name="moltke1">{{cite news |title=CHOLERA KILLS BOY; EIGHTH DEATH HERE; All Other Suspected Cases Now in Quarantine and Show No Alarming Symptoms. |url=https://www.nytimes.com/1911/07/18/archives/cholera-kills-boy-eighth-death-here-all-other-suspected-cases-now.html |work=The New York Times |date=18 July 1911 }}</ref><ref name="moltke2">{{cite news |title=More Cholera in Port |url=https://pqasb.pqarchiver.com/washingtonpost_historical/access/250061412.html?dids=250061412:250061412&FMT=ABS&FMTS=ABS:FT&date=OCT+10%2C+1910&author=&pub=The+Washington+Post&desc=MORE+CHOLERA+IN+PORT&pqatl=google |quote=A case of cholera developed today in the steerage of the Hamburg-American liner [[SMS Moltke (1877)|Moltke]], which has been detained at quarantine as a possible cholera carrier since Monday last. Dr. A.H. Doty, health officer of the port, reported the case tonight with the additional information that another cholera patient from the Moltke is under treatment at [[Swinburne Island]]. |newspaper=[[The Washington Post]] |date=October 10, 1910 |access-date=2008-12-11 |url-status=dead |archive-url=https://web.archive.org/web/20081216072507/http://pqasb.pqarchiver.com/washingtonpost_historical/access/250061412.html?dids=250061412%3A250061412&FMT=ABS&FMTS=ABS%3AFT&date=OCT+10%2C+1910&author=&pub=The+Washington+Post&desc=MORE+CHOLERA+IN+PORT&pqatl=google |archive-date=December 16, 2008 }}</ref> Cholera is mainly a risk in [[Developing country|developing countries]] in those areas where access to [[WASH|WASH (water, sanitation and hygiene)]] infrastructure is still inadequate.

Effective sanitation practices, if instituted and adhered to in time, are usually sufficient to stop an epidemic. There are several points along the cholera transmission path at which its spread may be halted:<ref>{{Cite web|title=Cholera|url=https://www.who.int/news-room/fact-sheets/detail/cholera|access-date=2020-08-20|website=www.who.int|language=en}}</ref>
* Sterilization: Proper disposal and treatment of all materials that may have come into contact with the feces of other people with cholera (e.g., clothing, bedding, etc.) are essential. These should be [[Disinfection|sanitized]] by washing in hot water, using [[chlorine]] [[bleach]] if possible. Hands that touch cholera patients or their clothing, bedding, etc., should be thoroughly cleaned and disinfected with chlorinated water or other effective antimicrobial agents.
* [[Sewage]] and [[fecal sludge management]]: In cholera-affected areas, sewage and fecal sludge need to be treated and managed carefully in order to stop the spread of this disease via [[human excreta]]. Provision of [[sanitation]] and [[hygiene]] is an important preventative measure.<ref name="who.int" /> [[Open defecation]], release of untreated sewage, or dumping of fecal sludge from [[pit latrine]]s or [[septic tank]]s into the environment need to be prevented.<ref>{{Cite book|url=https://books.google.com/books?id=AGQVBeNM_80C&pg=PA5|title=Urban Water Security: Managing Risks: UNESCO-IHP|last1=Cisneros|first1=Blanca Jimenez|last2=Rose|first2=Joan B. |date=2009-03-24|publisher=CRC Press|isbn=978-0-203-88162-0|language=en}}</ref> In many cholera affected zones, there is a low degree of [[sewage treatment]].<ref>{{Cite book|url=https://books.google.com/books?id=rd3zCAAAQBAJ&pg=GBS.PA24|title=Cholera and the Ecology of Vibrio cholerae| vauthors = Drasar BS, Forrest DB  |date=2012-12-06|publisher=Springer Science & Business Media|isbn=978-94-009-1515-2|page=24}}</ref><ref>{{Cite book|url=https://books.google.com/books?id=dAT9CgAAQBAJ&pg=PA219|title=A Companion to the Anthropology of Environmental Health|last=Singer|first=Merrill  |date=2016-05-31|publisher=John Wiley & Sons|isbn=978-1-118-78699-4|page=219}}</ref> Therefore, the implementation of [[dry toilet]]s that do not contribute to [[water pollution]], as they do not flush with water, may be an interesting alternative to [[flush toilet]]s.<ref>{{cite news |last1=Gili |first1=Enrique |date=9 June 2015 |title=Starting a poop to compost movement |url=https://www.dw.com/en/global-ideas-haiti-poop-compost-toilets/a-18504469 |work=Deutsche Welle }}</ref>
* Sources: Warnings about possible cholera contamination should be posted around contaminated water sources with directions on how to [[decontamination|decontaminate]] the water (boiling, chlorination etc.) for possible use.
* [[Water purification]]: All water used for drinking, washing, or cooking should be sterilized by either boiling, [[Water chlorination|chlorination]], ozone water treatment, ultraviolet light sterilization (e.g., by [[solar water disinfection]]), or antimicrobial filtration in any area where cholera may be present. Chlorination and boiling are often the least expensive and most effective means of halting transmission. [[Cloth filter]]s or [[#Sari filtration|sari filtration]], though very basic, have significantly reduced the occurrence of cholera when used in poor villages in [[Bangladesh]] that rely on untreated surface water. Better antimicrobial filters, like those present in advanced individual water treatment hiking kits, are most effective. Public health education and adherence to appropriate sanitation practices are of primary importance to help prevent and control transmission of cholera and other diseases.

[[Hand washing|Handwashing]] with soap or ash after using a [[toilet]] and before handling food or eating is also recommended for cholera prevention by WHO Africa.<ref>{{cite web |title=Cholera and food safety |url=http://who.insomnation.com/sites/default/files/pdf/fan_cholera%20fact%20sheet7.pdf |publisher=[[World Health Organization]] |access-date=2017-08-20 |url-status=dead |archive-url=https://web.archive.org/web/20170821044840/http://who.insomnation.com/sites/default/files/pdf/fan_cholera%20fact%20sheet7.pdf |archive-date=2017-08-21 }}</ref>

<gallery class="center" widths="225px" heights="200px">
File:Unsafe disposal of faecal sludge or sewage in Haiti (6458176073).jpg|Dumping of [[sewage]] or [[Fecal sludge management|fecal sludge]] from a UN camp into a lake in the surroundings of [[Port-au-Prince]] is thought to have contributed to the spread of [[2010 Haiti cholera outbreak|cholera after the Haiti earthquake in 2010]], killing thousands.
File:A SOIL EkoLakay toilet customer. (15921409131).jpg|Example of a [[urine-diverting dry toilet]] in a cholera-affected area in [[Haiti]]. This type of toilet stops transmission of disease via the [[Fecal–oral route|fecal-oral route]] due to [[water pollution]].
File:Cholera hospital in Dhaka.jpg|[[International Centre for Diarrhoeal Disease Research, Bangladesh|Cholera hospital]] in [[Dhaka]], showing typical "cholera beds"
</gallery>

=== Surveillance ===
[[File:Using Precipitation Data to Assess Risk of Cholera Outbreaks.webm|thumb|upright=1.3|A modelling approach using satellite data can enhance our ability to develop cholera risk maps in several regions of the globe.]]
Surveillance and prompt reporting allow for containing cholera epidemics rapidly. Cholera exists as a seasonal disease in many endemic countries, occurring annually mostly during [[Wet season|rainy seasons]]. Surveillance systems can provide early alerts to outbreaks, therefore leading to coordinated response and assist in preparation of preparedness plans. Efficient surveillance systems can also improve the risk assessment for potential cholera outbreaks. Understanding the seasonality and location of outbreaks provides guidance for improving cholera control activities for the most vulnerable.<ref>{{cite web |url=https://www.who.int/topics/cholera/control/en/index.html |title=Cholera: prevention and control |publisher=WHO |work=Health topics |year=2008 |access-date=2008-12-08 |url-status=dead |archive-url=https://web.archive.org/web/20081214042133/http://www.who.int/topics/cholera/control/en/index.html |archive-date=2008-12-14 }}</ref> For prevention to be effective, it is important that cases be reported to national health authorities.<ref name=Lancet2004 />

=== Vaccination ===
{{Main|Cholera vaccine}}
[[File:Euvichol-plus.jpg|thumb|Euvichol-plus oral vaccine for cholera]]
Spanish physician [[Jaume Ferran i Clua]] developed the first successful cholera inoculation in 1885, the first to immunize humans against a bacterial disease.<ref>{{Cite web|url=http://www.historyofvaccines.org/content/timelines/others|archive-url=https://web.archive.org/web/20150211100824/http://www.historyofvaccines.org/content/timelines/others|url-status=deviated|title=Others — Timelines — History of Vaccines|archive-date=February 11, 2015}}</ref> His vaccine and inoculation was rather controversial and was rejected by his peers and several investigation commissions but it ended up demonstrating its effectiveness and being recognized for it: out of the 30 thousand people he vaccinated only 54 died.<ref name=":0">{{cite journal |last1=Bornside |first1=George H. |title=Waldemar Haffkine's Cholera Vaccines and the Ferran-Haffkine Priority Dispute |journal=Journal of the History of Medicine and Allied Sciences |date=1982 |volume=XXXVII |issue=4 |pages=399–422 |doi=10.1093/jhmas/xxxvii.4.399 |pmid=6759570 }}</ref><ref name=":1">{{cite journal |last1=Bornside |first1=George H. |title=Jaime Ferran and Preventive Inoculation Against Cholera |journal=Bulletin of the History of Medicine |date=1981 |volume=55 |issue=4 |pages=516–532 |jstor=44441415 |pmid=7039738 }}</ref><ref name=":2">{{cite journal |last1=Hawgood |first1=Barbara J |title=Waldemar Mordecai Haffkine, CIE (1860–1930): prophylactic vaccination against cholera and bubonic plague in British India |journal=Journal of Medical Biography |date=February 2007 |volume=15 |issue=1 |pages=9–19 |doi=10.1258/j.jmb.2007.05-59 |pmid=17356724 |s2cid=42075270 }}</ref><ref>{{Cite journal |last1=Lopez |first1=Anna Lena |last2=Gonzales |first2=Maria Liza Antoinette |last3=Aldaba |first3=Josephine G. |last4=Nair |first4=G. Balakrish |date=September 2014 |title=Killed oral cholera vaccines: history, development and implementation challenges |journal=Therapeutic Advances in Vaccines |volume=2 |issue=5 |pages=123–136 |doi=10.1177/2051013614537819 |issn=2051-0136 |pmc=4144262 |pmid=25177492}}</ref> Russian-French bacteriologist [[Waldemar Haffkine]] also developed a human cholera vaccine in July 1892.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref>[http://www.haffkineinstitute.org/waldemar.htm haffkineinstitute.org] {{webarchive|url=https://web.archive.org/web/20150924024552/http://www.haffkineinstitute.org/waldemar.htm|date=2015-09-24}}</ref> He conducted a massive inoculation program in [[British India]].<ref name=":2" /><ref>{{Cite news|date=2020-12-11|title=Waldemar Haffkine: The vaccine pioneer the world forgot|language=en-GB|work=BBC News|url=https://www.bbc.com/news/world-asia-india-55050012|access-date=2021-01-20}}</ref>

Persons who survive an episode of cholera have long-lasting immunity for at least 3 years (the period tested).<ref name="immunity"/> A number of safe and effective oral vaccines for cholera are available.<ref name="pmid21412922">{{cite journal | vauthors = Sinclair D, Abba K, Zaman K, Qadri F, Graves PM | title = Oral vaccines for preventing cholera | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD008603 | date = March 2011 | volume = 2011 | pmid = 21412922 | pmc = 6532691 | doi = 10.1002/14651858.CD008603.pub2 | editor = Sinclair D }}</ref> The World Health Organization (WHO) has three prequalified oral cholera vaccines (OCVs): Dukoral, Sanchol, and Euvichol. [[Dukoral]], an orally administered, inactivated [[whole-cell vaccine]], has an overall efficacy of about 52% during the first year after being given and 62% in the second year, with minimal side effects.<ref name="pmid21412922" /> It is available in over 60 countries. However, it is not currently{{when|date=August 2017}} recommended by the [[Centers for Disease Control and Prevention]] (CDC) for most people traveling from the United States to endemic countries.<ref name="CDC_Vacc">{{cite web| title=Is a vaccine available to prevent cholera?| work=CDC disease info: Cholera| url=https://www.cdc.gov/cholera/general/#vaccine| date=2010-10-22| access-date=2010-10-24| url-status=live| archive-url=https://web.archive.org/web/20101026085158/http://www.cdc.gov/cholera/general/#vaccine| archive-date=2010-10-26}}</ref> The vaccine that the [[Food and Drug Administration|US Food and Drug Administration]] (FDA) recommends, [[Vaxchora]], is an [[Cholera vaccine#Oral|oral attenuated live vaccine]], that is effective for adults aged 18–64 as a single dose.<ref>{{Cite web|url=http://www.immunize.org/fda/|archiveurl=https://web.archive.org/web/20170415125256/http://www.immunize.org/fda/|url-status=dead|title=FDA Product Approval: View All|archivedate=April 15, 2017}}</ref>

One injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than five years old.<ref>{{cite journal | vauthors = Graves PM, Deeks JJ, Demicheli V, Jefferson T | title = Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD000974 | date = August 2010 | volume = 2019 | pmid = 20687062 | pmc = 6532721 | doi = 10.1002/14651858.CD000974.pub2 | editor = Graves PM }}</ref> However, {{as of|2010|lc=y}}, it has limited availability.<ref name=WHO2010 /> Work is under way to investigate the role of mass vaccination.<ref>{{cite web |url=https://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 |access-date=2010-02-01 |url-status=dead |archive-url=https://web.archive.org/web/20100216224558/http://who.int/topics/cholera/vaccines/en/index.html |archive-date=2010-02-16 }}</ref> The WHO recommends immunization of high-risk groups, such as children and people with [[HIV]], in countries where this disease is [[Endemism|endemic]].<ref name=WHO2010 /> If people are immunized broadly, [[herd immunity]] results, with a decrease in the amount of contamination in the environment.<ref name=NEJM2006 />

WHO recommends that oral cholera vaccination be considered in areas where the disease is endemic (with seasonal peaks), as part of the response to outbreaks, or in a humanitarian crisis during which the risk of cholera is high.<ref>{{cite journal |title=News from the World Health Organization: Epidemiological Methods for Environmental Health Initiatives in WHO |journal=International Journal of Epidemiology |date=1993 |volume=22 |issue=5 |pages=961–962 |doi=10.1093/ije/22.5.961 }}</ref> OCV has been recognized as an adjunct tool for prevention and control of cholera. The WHO has prequalified three bivalent cholera vaccines—Dukoral (SBL Vaccines), containing a non-toxic B-subunit of cholera toxin and providing protection against ''V.&nbsp;cholerae'' O1; and two vaccines developed using the same transfer of technology—ShanChol (Shantha Biotec) and Euvichol (EuBiologics Co.), which have bivalent O1 and O139 oral killed cholera vaccines.<ref>{{cite journal|vauthors=Ryan ET|date=January 2011|title=The cholera pandemic, still with us after half a century: time to rethink|journal=PLOS Neglected Tropical Diseases|volume=5|issue=1|pages=e1003|doi=10.1371/journal.pntd.0001003|pmc=3026764|pmid=21283611 |doi-access=free }}</ref> Oral cholera vaccination could be deployed in a diverse range of situations from cholera-endemic areas and locations of humanitarian crises, but no clear consensus exists.<ref>{{cite journal|vauthors=Deen J, von Seidlein L, Luquero FJ, Troeger C, Reyburn R, Lopez AL, Debes A, Sack DA|date=January 2016|title=The scenario approach for countries considering the addition of oral cholera vaccination in cholera preparedness and control plans|journal=The Lancet. Infectious Diseases|volume=16|issue=1|pages=125–129|doi=10.1016/S1473-3099(15)00298-4|pmid=26494426|doi-access=}}</ref>

=== Sari filtration ===
{{Main|Cloth filter}} 
[[Image:Washing Utensils And Vegetables.png|Women at a village pond in [[Matlab, Bangladesh]], washing utensils and vegetables. The woman on the right is putting a sari filter onto a water-collecting pot (or [[Kalasha|kalash]]) to filter water for drinking.|thumb|240px]]

Developed for use in [[Bangladesh]], the "sari filter" is a simple and cost-effective [[appropriate technology]] method for reducing the contamination of drinking water. Used [[sari]] cloth is preferable but other types of used cloth can be used with some effect, though the effectiveness will vary significantly. Used cloth is more effective than new cloth, as the repeated washing reduces the space between the fibers. Water collected in this way has a greatly reduced [[pathogen]] count—though it will not necessarily be perfectly safe, it is an improvement for poor people with limited options.<ref name=Ram2010>{{cite book|author=Ramamurthy T|title=Epidemiological and Molecular Aspects on Cholera|year=2010|publisher=Springer|isbn=978-1-60327-265-0|page=330|url=https://books.google.com/books?id=X1DI0Easu2YC&pg=PA330|url-status=live|archive-url=https://web.archive.org/web/20151107134836/https://books.google.com/books?id=X1DI0Easu2YC&pg=PA330|archive-date=2015-11-07}}</ref> In Bangladesh this practice was found to decrease rates of cholera by nearly half.<ref name=Merr2010>{{cite book|author=Merrill RM|title=Introduction to epidemiology.|year=2010|publisher=Jones and Bartlett Publishers|location=Sudbury, MA|isbn=978-0-7637-6622-1|page=43|url=https://books.google.com/books?id=RMDBh6gw1_UC&pg=PA43|edition=5th|url-status=live|archive-url=https://web.archive.org/web/20151106194307/https://books.google.com/books?id=RMDBh6gw1_UC&pg=PA43|archive-date=2015-11-06}}</ref> It involves folding a ''sari'' four to eight times.<ref name=Ram2010 /> Between uses the cloth should be rinsed in clean water and dried in the sun to kill any bacteria on it.<ref>{{cite book|author=Starr C|title=Biology: Today and Tomorrow with Physiology|year=2007|publisher=Cengage Learning|isbn=978-1-111-79701-0|page=563|url=https://books.google.com/books?id=-bsFAAAAQBAJ&pg=PA563|edition=2|url-status=live|archive-url=https://web.archive.org/web/20151107022134/https://books.google.com/books?id=-bsFAAAAQBAJ&pg=PA563|archive-date=2015-11-07}}</ref> A [[nylon]] cloth appears to work as well but is not as affordable.<ref name=Merr2010 />