First Cholera Vaccine Approved in the US: Information for Pharmacists

US adults traveling to cholera-affected areas can now be vaccinated against the disease, as the FDA recently approved Vaxchora, the first immunization available in the United States for cholera prevention.

Cholera, which is caused by the bacteria Vibrio cholerae, isn’t a common cause for concern within US borders. However, it’s a significant global health issue, particularly in areas of Africa, Asia, and Central America. In fact, current outbreaks are reported in the Democratic Republic of the Congo, Kenya, Malawi, Mozambique, Tanzania, and Zambia.

V. cholerae typically causes an acute illness characterized by diarrhea presenting 2 to 3 days following bacterial infection. Although symptoms are often mild, approximately 5% to 10% of infected individuals develop profuse watery diarrhea and vomiting with the potential for subsequent dehydration and associated symptoms of electrolyte imbalance. In those cases, immediate rehydration is required to prevent death and should be considered the mainstay of treatment.

Antibiotic therapy is reserved for severe disease and should only be used in conjunction with rehydration to reduce diarrheal episodes and shorten the disease course. Options include azithromycin, ciprofloxacin, doxycycline, erythromycin, or tetracycline, although clinical guidelines differ on antibiotic treatment recommendations.

Perhaps the best option for cholera is prevention. V. cholerae is most commonly transmitted via the fecal-oral route and is often found in contaminated water and food sources. Additionally, the bacterium can grow in coastal waters. As a result, endemic areas are focusing on hygiene, sanitation, and water treatment as preventive measures.

Travelers to those areas should consider the following precautions to reduce their risk of cholera infection:

• Water Only drink water that has been boiled or treated. Bottled water is likely the safest option. Skip the ice unless you’re certain it was made with safe water. Don’t forget about water used in daily activities, such as brushing teeth, preparing meals, and washing dishes.
• Food Packaged food items and cooked dishes served hot are likely the safest options. Avoid raw or undercooked meat and seafood. Avoid fresh fruits and veggies without a peel, or make sure to wash these items with clean water prior to consumption.
• Hand Hygiene Wash hands with soap and clean water. An alcohol-based sanitizer may be an appropriate alternative. Avoid putting fingers in the mouth.

Vaxchora is an additional preventive measure for travelers to cholera-affected areas. This live, attenuated vaccine provides activity against V. cholerae serogroup O1, which is 1 of 2 toxigenic groups previously implicated in cholera epidemics.

• Indication Adults 18 to 64 years traveling to cholera-affected areas
• Dosage 100 mL by mouth once.
• Administration Immunization must be reconstituted prior to administration. Prior to reconstitution, remove both vaccine packets (buffer and active components) from freezer. Reconstitution should be completed within 15 minutes. In a disposable cup, place 100 mL of purified bottled water. Add buffer packet and stir until completely dissolved. Add active ingredient packet and stir until cloudy suspension forms. Won’t completely dissolve. Consume the full contents of the cup. Must be consumed within 15 minutes of reconstitution.
• Warnings/Precautions Caution should be used in immunocompromised patients. Following administration, Vaxchora may be found in the feces for at least 7 days. Caution should be used to prevent transmission to unvaccinated individuals.
• Adverse Reactions Tiredness, headache, abdominal pain, nausea, vomiting, lack of appetite, and diarrhea.
• Drug Interactions Don’t use with systemic antibiotics or in those who have received antibiotics in the 2 weeks preceding vaccination. Don’t use with chloroquine. As travelers may require prophylaxis against both cholera and malaria, the manufacturers of Vaxchora recommend administering the single-dose vaccine at least 10 days prior to beginning chloroquine prophylaxis.
• Patient Counseling Avoid consumption of food or drinks for 1 hour prior to and following Vaxchora administration. Vaxchora should be given at least 10 days prior to travel to cholera-affected areas.