Cholera primary prevention: Difference between revisions

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[[Image:Cholera_hospital_in_Dhaka.jpg|right|thumb|Cholera hospital in Dhaka.]]
__NOTOC__
{{Cholera}}
{{Cholera}}
{{CMG}}; '''Associate Editors-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, MBBS]] [mailto:psingh@perfuse.org]
{{CMG}}; '''Associate Editors-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, MBBS]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
Although cholera can be life-threatening, it is nearly always easily prevented, in principle, if proper sanitation practices are followed. In the United States and Western Europe, because of advanced [[water treatment]] and sanitation systems, cholera is no longer a major threat. The last major outbreak of cholera in the United States was in 1911. However, everyone, especially travelers, should be aware of how the disease is transmitted and what can be done to prevent it. Good sanitation practices, if instituted in time, are usually sufficient to stop an epidemic.
Primary prevention of cholera can be achieved on an individual level by appropriate personal hygiene, use of sanitary water supply, appropriate preparation of food, as well as prompt identification, isolation, and treatment of cases. Primary preventive methods may also be implemented on a community level through effective water sanitation, appropriate and broad vaccination of the community to develop [[herd immunity]] as well as early detection of an outbreak.<ref name="pmid23301693">{{cite journal| author=Waldman RJ, Mintz ED, Papowitz HE| title=The cure for cholera--improving access to safe water and sanitation. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 7 | pages= 592-4 | pmid=23301693 | doi=10.1056/NEJMp1214179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23301693  }} </ref><ref name="pmid16326125">{{cite journal| author=Sepúlveda J, Valdespino JL, García-García L| title=Cholera in Mexico: the paradoxical benefits of the last pandemic. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 1 | pages= 4-13 | pmid=16326125 | doi=10.1016/j.ijid.2005.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16326125  }} </ref><ref name="pmid17141709">{{cite journal| author=Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G et al.| title=Improvement of child survival in Mexico: the diagonal approach. | journal=Lancet | year= 2006 | volume= 368 | issue= 9551 | pages= 2017-27 | pmid=17141709 | doi=10.1016/S0140-6736(06)69569-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17141709  }} </ref><ref>{{cite journal |author=Graves PM, Deeks JJ, Demicheli V, Jefferson T |title=Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) |journal=Cochrane Database Syst Rev |volume= |issue=8 |pages=CD000974 |year=2010 |pmid=20687062 |doi=10.1002/14651858.CD000974.pub2 |url= |editor1-last=Graves |editor1-first=Patricia M}}</ref><ref name="pmid21412922">{{cite journal |author=Sinclair D, Abba K, Zaman K, Qadri F, Graves PM |title=Oral vaccines for preventing cholera |journal=Cochrane Database Syst Rev |issue=3 |pages=CD008603 |year=2011 |doi=10.1002/14651858.CD008603.pub2 |pmid=21412922}}</ref><ref>{{cite web |url=http://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 | accessdate=2010-02-01}}</ref>


==Primary prevention==
==Primary Prevention==
===Signals of an outbreak===
===Individual Prevention===
* Increase number of acute diarrhoeal cases and patients having common symptoms-
Effective methods for individual primary prevention of [[cholera]] include:<ref name="pmid23301693">{{cite journal| author=Waldman RJ, Mintz ED, Papowitz HE| title=The cure for cholera--improving access to safe water and sanitation. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 7 | pages= 592-4 | pmid=23301693 | doi=10.1056/NEJMp1214179 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23301693  }} </ref><ref name="pmid16326125">{{cite journal| author=Sepúlveda J, Valdespino JL, García-García L| title=Cholera in Mexico: the paradoxical benefits of the last pandemic. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 1 | pages= 4-13 | pmid=16326125 | doi=10.1016/j.ijid.2005.05.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16326125  }} </ref><ref name="pmid17141709">{{cite journal| author=Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G et al.| title=Improvement of child survival in Mexico: the diagonal approach. | journal=Lancet | year= 2006 | volume= 368 | issue= 9551 | pages= 2017-27 | pmid=17141709 | doi=10.1016/S0140-6736(06)69569-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17141709  }} </ref>
** Watery diarrhoea, dehydration and vomiting
*Practice appropriate hand washing and personal hygiene
** Cases from same area or location
*Avoid defecation in bodies of water
** Eaten the same food (for e.g. at a burial ceremony)
*Appropriate preparation and cooking of food (e.g., seafood)
** Sharing the same water source
*Peeling of fruits and vegetables
** Outbreak in the neighboring community
*Use of sanitary water supply
===Steps in case of suspected cholera outbreak===
* Inform and ask for help (supervisor, other centers)
* Treat patients promptly specially patients presenting as some or severe cholera symptoms (as they may deteriorate rapidly)
* Protect the community (prevent spread to others)
===Checklist for medical professionals in case of suspected outbreak===
In case of suspected [[cholera]] in community, medical professionals and hospitals should check the supplies to treat the patients.
* IV fluids (Ringer Lactate is the best, in case of nonavailability of ringer lactate cholera saline or normal saline can be used)
* [[Oral Rehydration Salt]] ([[ORS]])
* Antibiotics ([[doxycycline]], [[erythromycin]], [[tetracycline]])
* Rectal swabs and transport medium (Cary Blair or TCBS) for stool samples
* Safe water is needed to rehydrate patients and to wash clothes and instruments
* Chlorine or bleaching powder
* Nasogastric tubes
* Drips
* Soap
===Steps to protect the community===
There are several points along the transmission path at which the spread may be halted:
* Sickbed: Isolate the severe cases. Proper disposal and treatment of the germ infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
* Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
* Sources: Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.
* [[Sterilization]]: Boiling, filtering, and chlorination of water kill the bacteria produced by cholera patients and prevent infections, when they do occur, from spreading. All materials (clothing, bedding, etc.) that come in contact with cholera patients should be sterilized in hot water using (if possible) chlorine bleach. Hands, etc. that touch cholera patients or their clothing etc. should be thoroughly cleaned and sterilized. All water used for drinking, washing or cooking should be sterilized by boiling or chlorination in any area where cholera may be present. Water filtration, chlorination and boiling are by far the most effective means of halting transmission. Cloth filters, though very basic, have greatly reduced the occurrence of cholera when used in poor villages in Bangladesh that rely on untreated surface water. In general, public health education and good sanitation practices are the limiting factors in preventing transmission. Wash your hands with soap after using toilets and latrines, before preparing food, before eating
* Only eat freshly cooked food
* Do not defecate near the water sources
* Use latrines and keep them clean


===Sari filtration===
===Prevention in the Community===
* An effective and relatively cheap method to prevent transmission of ''V. cholera'' is the practice of folding a [[sari]] (a long fabric garment) multiple times to create a simple filter for drinking water.<ref>{{cite journal |author=Ali M, Emch M, Yunus M, Sack D, Lopez AL, Holmgren J, Clemens J |title=Vaccine Protection of Bangladeshi infants and young children against cholera: implications for vaccine deployment and person-to-person transmission |journal=Pediatr Infect Dis J |volume=27 |issue=1 |pages=33–7 |month=Jan |year=2008 |doi=10.1097/INF.0b013e318149dffd |pmid=18162935}}</ref>
Primary prevention of [[cholera]] in the community include:
* Folding saris four to eight times may create a simple filter to reduce the amount of active ''V. cholera'' in the filtered water.<ref>Z. Bhutta. Background Paper on the Integration of Oral Cholera Vaccines into Global Cholera Control Programmes. To be presented to the WHO SAGE in October 2009</ref>
* Broad vaccination of the community for [[herd immunity]]
* The education of proper sari filter use is imperative, as there is a positive correlation between sari misuse and the incidence of childhood diarrhea; soiled saris worn by women are vectors of transmission of enteric pathogens to young children.<ref>{{cite journal |author=Stanton BF, Clemens JD, Clements JD |title=Soiled saris: a vector of disease transmission? |journal=Trans R Soc Trop Med Hyg |volume=80 |issue=3 |pages=485–8 |year=1986 |pmid=3798547}}</ref> Educating at-risk populations about the proper use of the sari filter method may decrease ''V. cholera''-associated disease.
* '''Sickbed:''' Isolate the severe cases. Proper disposal and treatment of the germ-infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
===Precautions for funerals===
* '''Sewage:''' Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
* Disinfect corpses with chlorine solution (2%)
* '''Education:''' Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.
* Fill mouth and anus with cotton wool soaked with chlorine solution
 
* Wash hands with soap after touching the corpse
===Prevention in Healthcare settings===
* Disinfect the clothing and bedding of the deceased by stirring them in boiling water or by drying them thoroughly in the sun
Primary Prevention in a health care setting includes appropriate sanitation of potentially infected surfaces and equipment as follows:<ref name="cdc chlorine">Center for Disease Control Infection Control Guideline HCP. http://www.cdc.gov/cholera/infection-control-hcp.html Accessed on October 7th, 2016</ref>
*2% chlorine
**Made by mixing 3 parts water and 2 parts bleach
**Used for disinfecting vomit, feces, and corpses
*0.5% chlorine
**Made by mixing 9 parts water and 1 part bleach
**Used for foot baths, cleaning floors, bedding, latrines
*0.05% chlorine
**Made by mixing 9 parts water and 1 part 0.5% chlorine solution
**Used for bathing soiled patients, handwashing, rinsing dishes, laundry
===Vaccine===
===Vaccine===
[[Cholera vaccine]]
A number of safe and effective oral [[vaccines]] for cholera are available.<ref name="pmid21412922">{{cite journal |author=Sinclair D, Abba K, Zaman K, Qadri F, Graves PM |title=Oral vaccines for preventing cholera |journal=Cochrane Database Syst Rev |issue=3 |pages=CD008603 |year=2011 |doi=10.1002/14651858.CD008603.pub2 |pmid=21412922}}</ref> 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 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=http://www.cdc.gov/cholera/general/#vaccine| date=2010-10-22| accessdate=2010-10-24}}</ref> ShanChol is another oral [[vaccination]] which is based on the O1 and O139 serotypes.<ref name="who"> World Health Organization Cholera Epidemiological Report. http://www.who.int/wer/2012/wer8731_32.pdf. Accessed on October 7th, 2016</ref>. An injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.<ref>{{cite journal |author=Graves PM, Deeks JJ, Demicheli V, Jefferson T |title=Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) |journal=Cochrane Database Syst Rev |volume= |issue=8 |pages=CD000974 |year=2010 |pmid=20687062 |doi=10.1002/14651858.CD000974.pub2 |url= |editor1-last=Graves |editor1-first=Patricia M}}</ref> However, as of 2010, it has limited availability. Work is underway to investigate the role of mass [[vaccination]].<ref>{{cite web |url=http://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 | accessdate=2010-02-01}}</ref> The [[World Health Organization]] (WHO) recommends immunization of high risk groups, such as children and people with [[HIV]], in countries where this disease is [[endemic]]. If people are immunized broadly, [[herd immunity]] results, with a decrease in the amount of contamination in the environment.
 
===Signals of an Outbreak===
Increase number of acute diarrhea cases and patients having common symptoms:
* Watery [[diarrhea]], [[dehydration]] and [[vomiting]]
* Cases from same area or location
* Eaten the same food (e.g., at a burial ceremony)
* Sharing the same water source
* Outbreak in the neighboring community
 
==Risk for travellers==
Risk for travellers is low even in epidemic regions. However, humanitarian relief workers in disaster areas and refugee camps may be at risk.
==General precautions==
*Cholera vaccination is not required as a condition of entry to any country.
*Avoid drinking or eating unsafe water or foods.
==Vaccine==
*Oral vaccine consisting of killed whole-cell V. cholerae O1 in combination with a recombinant B-subunit of cholera toxin (WC/rBS).
*Primary immunization consists of two oral doses  ≥7 days (but <6 weeks) apart for adults and children aged 6 years and over.
*For children aged 2–5 years, three doses are recommended.
*Following primary immunization, protection against cholera may be expected after about 1 week.
*The vaccine is not licensed for children under 2 years of age.
 
== Summary of vaccine data ==
{| class="wikitable"
!
!Considerations
|-
| rowspan="2" |Type of vaccine
|Killed oral O1 whole-cell with Bsubunit.
|-
|Killed oral O1 and O139.
|-
| rowspan="2" |Number of doses
|
* Two doses (minimum 1 week and maximum 6 weeks apart).


A number of safe and effective oral vaccines for cholera are available.<ref name="pmid21412922">{{cite journal |author=Sinclair D, Abba K, Zaman K, Qadri F, Graves PM |title=Oral vaccines for preventing cholera |journal=Cochrane Database Syst Rev |issue=3 |pages=CD008603 |year=2011 |doi=10.1002/14651858.CD008603.pub2 |pmid=21412922}}</ref> [[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 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=http://www.cdc.gov/cholera/general/#vaccine| date=2010-10-22| accessdate=2010-10-24}}</ref> One injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.<ref>{{cite journal |author=Graves PM, Deeks JJ, Demicheli V, Jefferson T |title=Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected) |journal=Cochrane Database Syst Rev |volume= |issue=8 |pages=CD000974 |year=2010 |pmid=20687062 |doi=10.1002/14651858.CD000974.pub2 |url= |editor1-last=Graves |editor1-first=Patricia M}}</ref> However, as of 2010, it has limited availability.<ref name=WHO2010/> Work is under way to investigate the role of mass vaccination.<ref>{{cite web |url=http://www.who.int/topics/cholera/vaccines/en/index.html |title=Cholera vaccines |publisher=WHO |work=Health topics |year=2008 | accessdate=2010-02-01}}</ref> The World Health Organization (WHO) recommends immunization of high risk groups, such as children and people with [[HIV]], in countries where this disease is [[Endemism|endemic]]. If people are immunized broadly, [[herd immunity]] results, with a decrease in the amount of contamination in the environment.
* Three doses for children aged 2–5 years (minimum 1 week and maximum 6 weeks apart)
|-
|
* Two doses 14 days apart for individuals aged ≥2 years. One booster dose is recommended after 2 years.
|-
|Contraindications
|Hypersensitivity to previous dose.
|-
|Adverse reactions
|Mild gastrointestinal disturbances.
|-
|Before departure
|2 weeks.
|-
|Indication
|Travellers at high risk (e.g. emergency/relief workers).
|}


==References==
 
== References ==
{{Reflist|2}}
{{Reflist|2}}
== External links ==
[http://whqlibdoc.who.int/hq/2010/WHO_CDS_CSR_NCS_2003.7_Rev.2_eng.pdf WHO]


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Latest revision as of 20:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

Overview

Primary prevention of cholera can be achieved on an individual level by appropriate personal hygiene, use of sanitary water supply, appropriate preparation of food, as well as prompt identification, isolation, and treatment of cases. Primary preventive methods may also be implemented on a community level through effective water sanitation, appropriate and broad vaccination of the community to develop herd immunity as well as early detection of an outbreak.[1][2][3][4][5][6]

Primary Prevention

Individual Prevention

Effective methods for individual primary prevention of cholera include:[1][2][3]

  • Practice appropriate hand washing and personal hygiene
  • Avoid defecation in bodies of water
  • Appropriate preparation and cooking of food (e.g., seafood)
  • Peeling of fruits and vegetables
  • Use of sanitary water supply

Prevention in the Community

Primary prevention of cholera in the community include:

  • Broad vaccination of the community for herd immunity
  • Sickbed: Isolate the severe cases. Proper disposal and treatment of the germ-infected fecal waste (and all clothing and bedding that come in contact with it) produced by cholera victims is of primary importance as stool and vomit are highly contagious
  • Sewage: Treatment of general sewage before it enters the waterways or underground water supplies prevent possible undetected patients from spreading the disease.
  • Education: Warnings about cholera contamination posted around contaminated water sources through simple messages with directions on how to decontaminate the water.

Prevention in Healthcare settings

Primary Prevention in a health care setting includes appropriate sanitation of potentially infected surfaces and equipment as follows:[7]

  • 2% chlorine
    • Made by mixing 3 parts water and 2 parts bleach
    • Used for disinfecting vomit, feces, and corpses
  • 0.5% chlorine
    • Made by mixing 9 parts water and 1 part bleach
    • Used for foot baths, cleaning floors, bedding, latrines
  • 0.05% chlorine
    • Made by mixing 9 parts water and 1 part 0.5% chlorine solution
    • Used for bathing soiled patients, handwashing, rinsing dishes, laundry

Vaccine

A number of safe and effective oral vaccines for cholera are available.[5] 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.[5] It is available in over 60 countries. However, it is not currently recommended by the Centers for Disease Control and Prevention (CDC) for most people traveling from the United States to endemic countries.[8] ShanChol is another oral vaccination which is based on the O1 and O139 serotypes.[9]. An injectable vaccine was found to be effective for two to three years. The protective efficacy was 28% lower in children less than 5 years old.[10] However, as of 2010, it has limited availability. Work is underway to investigate the role of mass vaccination.[11] The World Health Organization (WHO) recommends immunization of high risk groups, such as children and people with HIV, in countries where this disease is endemic. If people are immunized broadly, herd immunity results, with a decrease in the amount of contamination in the environment.

Signals of an Outbreak

Increase number of acute diarrhea cases and patients having common symptoms:

  • Watery diarrhea, dehydration and vomiting
  • Cases from same area or location
  • Eaten the same food (e.g., at a burial ceremony)
  • Sharing the same water source
  • Outbreak in the neighboring community

Risk for travellers

Risk for travellers is low even in epidemic regions. However, humanitarian relief workers in disaster areas and refugee camps may be at risk.

General precautions

  • Cholera vaccination is not required as a condition of entry to any country.
  • Avoid drinking or eating unsafe water or foods.

Vaccine

  • Oral vaccine consisting of killed whole-cell V. cholerae O1 in combination with a recombinant B-subunit of cholera toxin (WC/rBS).
  • Primary immunization consists of two oral doses ≥7 days (but <6 weeks) apart for adults and children aged 6 years and over.
  • For children aged 2–5 years, three doses are recommended.
  • Following primary immunization, protection against cholera may be expected after about 1 week.
  • The vaccine is not licensed for children under 2 years of age.

Summary of vaccine data

Considerations
Type of vaccine Killed oral O1 whole-cell with Bsubunit.
Killed oral O1 and O139.
Number of doses
  • Two doses (minimum 1 week and maximum 6 weeks apart).
  • Three doses for children aged 2–5 years (minimum 1 week and maximum 6 weeks apart)
  • Two doses 14 days apart for individuals aged ≥2 years. One booster dose is recommended after 2 years.
Contraindications Hypersensitivity to previous dose.
Adverse reactions Mild gastrointestinal disturbances.
Before departure 2 weeks.
Indication Travellers at high risk (e.g. emergency/relief workers).


References

  1. ↑ 1.0 1.1 Waldman RJ, Mintz ED, Papowitz HE (2013). "The cure for cholera--improving access to safe water and sanitation". N Engl J Med. 368 (7): 592–4. doi:10.1056/NEJMp1214179. PMID 23301693.
  2. ↑ 2.0 2.1 Sepúlveda J, Valdespino JL, García-García L (2006). "Cholera in Mexico: the paradoxical benefits of the last pandemic". Int J Infect Dis. 10 (1): 4–13. doi:10.1016/j.ijid.2005.05.005. PMID 16326125.
  3. ↑ 3.0 3.1 Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G; et al. (2006). "Improvement of child survival in Mexico: the diagonal approach". Lancet. 368 (9551): 2017–27. doi:10.1016/S0140-6736(06)69569-X. PMID 17141709.
  4. ↑ Graves PM, Deeks JJ, Demicheli V, Jefferson T (2010). Graves, Patricia M, ed. "Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected)". Cochrane Database Syst Rev (8): CD000974. doi:10.1002/14651858.CD000974.pub2. PMID 20687062.
  5. ↑ 5.0 5.1 5.2 Sinclair D, Abba K, Zaman K, Qadri F, Graves PM (2011). "Oral vaccines for preventing cholera". Cochrane Database Syst Rev (3): CD008603. doi:10.1002/14651858.CD008603.pub2. PMID 21412922.
  6. ↑ "Cholera vaccines". Health topics. WHO. 2008. Retrieved 2010-02-01.
  7. ↑ Center for Disease Control Infection Control Guideline HCP. http://www.cdc.gov/cholera/infection-control-hcp.html Accessed on October 7th, 2016
  8. ↑ "Is a vaccine available to prevent cholera?". CDC disease info: Cholera. 2010-10-22. Retrieved 2010-10-24.
  9. ↑ World Health Organization Cholera Epidemiological Report. http://www.who.int/wer/2012/wer8731_32.pdf. Accessed on October 7th, 2016
  10. ↑ Graves PM, Deeks JJ, Demicheli V, Jefferson T (2010). Graves, Patricia M, ed. "Vaccines for preventing cholera: killed whole cell or other subunit vaccines (injected)". Cochrane Database Syst Rev (8): CD000974. doi:10.1002/14651858.CD000974.pub2. PMID 20687062.
  11. ↑ "Cholera vaccines". Health topics. WHO. 2008. Retrieved 2010-02-01.


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