Cholera Associated with International Travel, 1992

Approximately one case of cholera per week is being reported in the United States. Most of these cases have been acquired during international travel and involve persons who return to their homelands to visit family or foreign nationals visiting relatives in the United States. This report summarizes case reports from four states during 1992. Connecticut

On January 8, the Connecticut Department of Health Services was notified about suspected cholera in two persons. The first, a 43-year-old woman born in Ecuador, traveled with her daughters, aged 13 and 16 years, to Guayaquil, Ecuador, to visit relatives during the Christmas holidays. On January 3, the mother ate raw clams, and the 16-year-old ate cooked shrimp. The following evening, the mother ate cooked crab and lobster, and the 16-year-old ate cooked crab. The 13-year-old ate no seafood during the trip. On January 5, approximately 16 hours after the second meal, the mother had onset of vomiting, cramps, and diarrhea. On January 6, about 48 hours after the second meal and during the return flight to Connecticut, the 16-year-old developed similar symptoms.

Both persons were treated as outpatients at an emergency room in Connecticut with intravenous fluids and oral antimicrobials. Toxigenic Vibrio cholerae O1, biotype El Tor, serotype Inaba, was recovered from stool cultures of both persons. In addition, both Shigella and Campylobacter were isolated from the 16-year-old's stool. The 13-year-old daughter remained well. Florida

On June 8, the Florida Department of Health and Rehabilitative Services was notified of suspected cholera in a 48-year-old man born in Ecuador. The man and his brother traveled by air on June 4 from Guayaquil, Ecuador, to the United States to visit relatives in Miami. Before leaving Guayaquil, he ate ceviche at the airport restaurant. His brother had a different meal.

On the morning of June 6, the patient awoke with severe diarrhea and was hospitalized in Miami. He recovered and was discharged on the 5th hospital day. Culture of the patient's stool yielded toxigenic V. cholerae O1, biotype El Tor, serotype Ogawa. The patient's brother remained well. Hawaii

On July 30, the Hawaii Department of Health was notified about suspected cholera in a 58-year-old male traveler from the Philippines. On July 28, the man boarded a flight in Manila for Honolulu and Panama, where he was employed. Approximately 90 minutes into the flight, he developed severe diarrhea that continued for the duration of the 10.5-hour flight to Honolulu. No oral rehydration therapy was available on the airliner. Shortly before arrival in Honolulu, he had onset of nausea, vomiting, and dizziness.

On arrival, the patient was met by a CDC quarantine officer and was taken by ambulance to a hospital, where he was admitted to the intensive care unit in hypovolemic shock. A stool culture yielded toxigenic V. cholerae O1, biotype El Tor, serotype Ogawa. The patient received intravenous antimicrobials and approximately 10-12 liters of intravenous fluids daily for 5 days. He recovered and was discharged on the 7th hospital day. Texas

On April 29, the Texas Department of Health was notified of suspected cholera in a 40-year-old Hispanic male resident of Brownsville. On April 27, the man and his brother from Houston traveled by automobile to Tampico, Mexico, to visit their father. That evening, they ate fried shrimp and boiled crab at a restaurant in Tampico. The two men returned to Brownsville on April 28. Shortly after midnight, the man had onset of severe vomiting, diarrhea, and confusion; he was hospitalized at 6 a.m.

The emergency room physician suspected cholera. Motile vibrios were visible on a wet preparation of stool examined by darkfield microscopy, and toxigenic V. cholerae O1, biotype El Tor, serotype Inaba, was isolated from a stool sample. The isolate was similar to the Latin American strain by multilocus enzyme testing at CDC.

The man received 13 liters of fluid intravenously during the first day of hospitalization; he recovered and was discharged after 2 days. His brother reported mild diarrhea after the trip. His serum, obtained approximately 2 weeks after his illness, had no detectable vibriocidal antibodies, indicating that he had not had cholera.

Reported by: G Cooper, JL Hadler, MD, State Epidemiologist, Connecticut State Dept of Health Svcs. S Barth, PhD, RC Mullen, MPH, WG Hlady, MD, RS Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. J Kelly, Philippine Airlines (Honolulu station); S Castillo, FD Pien, MD, Straub Clinic and Hospital, Inc; HY Higa, VY Goo, MS, Div of Microbiology, LK Inouye, PhD, M Sugi, MPH, Div of Epidemiology, EW Pon, MD, State Epidemiologist, Hawaii Dept of Health. L Pelly, MD, Brownsville Medical Center, J Trevino, City of Brownsville Health Dept; GR Garza, A Calderin, South Texas Hospital Laboratory, Harlingen; NL Shelton, MPH, Houston Health and Human Svcs Dept; K Williams, Div of Microbiology, B Ray, K Hendricks, MD, DM Simpson, MD, State Epidemiologist, Texas Dept of Health. Div of Quarantine, National Center for Prevention Svcs; Enteric Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In 1991, 26 cases of cholera were reported in the United States; 18 were associated with travel to Latin America. Of these, 11 were related to crabs brought back in suitcases (1). Although no further domestic cholera cases associated with souvenir crab have occurred, the number of travel-associated cholera cases is increasing.

Since January 1, 1992, 96 cholera cases have been reported in the United States (with one death), more than in any year since CDC began cholera surveillance in 1961. Of these, 95 were travel-associated. In comparison, from 1961 to 1981, only 10 travel-associated cholera cases were reported (2). Of the 96 cases, 75 were associated with an outbreak on board an Aerolineas Argentinas flight between Argentina and Los Angeles (3). Of the remaining 21 cases, 14 have been linked with travel between the United States and Latin America and six with travel between the United States and Asia. The source of one patient's infection remains unknown. None of the 20 travel-associated cases occurred on typical tourist itineraries. Twelve of the 14 cases associated with travel to Latin America occurred in U.S. residents who were visiting relatives in Latin America; two occurred in residents of Latin America who were ill in the United States. Similarly, five of the six cases associated with travel to Asia occurred in persons visiting relatives.

Most persons infected with V. cholerae O1 have no symptoms, and attempts to prevent the introduction of cholera through restriction of travel have not been successful (4). Because immigrants or foreign nationals may not speak English and are unlikely to obtain pretravel medical advice, they may be difficult to reach with cholera-prevention messages. In addition, these persons may be exposed to cholera while staying in the households of relatives in their homelands.

The report of the Filipino traveler illustrates how a cholera strain could be introduced into another part of the world. Infected travelers can easily move from one part of the world affected by cholera to another where sanitary conditions may permit spread of cholera.

Although spread of cholera on an aircraft is unlikely if routine sanitary measures are followed, cabin crew of commercial aircraft traveling to and from areas affected by cholera should be prepared to treat passengers who develop symptoms of cholera. Most persons with cholera can be treated with oral rehydration solution (ORS) which can be kept on board in dehydrated packets. CDC has advised domestic and foreign airlines serving the western hemisphere and the International Air Transport Association to stock ORS and instructions in its use on flights to and from cholera-affected areas. With prompt and appropriate replacement of fluids, dehydration in persons with severe ongoing fluid losses can be prevented. Regardless of treatment en route, any patient suspected of having cholera should seek medical assistance immediately on arrival.

Risk for cholera and traveler's diarrhea can be reduced by following the general rule "boil it, cook it, peel it, or forget it" (5). In particular, travelers should not consume 1) unboiled or untreated water and ice made from such water; 2) food and beverages from street vendors; 3) raw or partially cooked fish and shellfish, including ceviche; and 4) uncooked vegetables. Cold seafood salads may be particularly risky. Travelers should eat only foods that are cooked and hot, or fruits they peel themselves. Carbonated bottled water and carbonated soft drinks are usually safe if no ice is added (6). Persons planning travel to cholera-affected areas may call the pretravel hotline made available through CDC in English ((404) 332-4559) and Spanish ((404) 330-3132).

References

1. CDC. Cholera -- New Jersey and Florida. MMWR 1991;40:287-9.

2. Synder JD, Blake PA. Is cholera a problem for U.S. travelers? JAMA 1982;247:2268-9.

3. CDC. Cholera associated with an international airline flight, 1992. MMWR 1992;41:134-5.

4. World Health Organization. Guidelines for cholera control. Geneva: World Health Organization, Programme for Control of Diarrhoeal Disease, 1992; publication no. WHO/CCD/SER/80.4, rev. 4.

5. Kozicki M, Steffen R, Schar M. "Boil it, cook it, peel it, or forget it": does this rule prevent travellers' diarrhoea? Int J Epidemiol 1985;14:169-72.

6. CDC. Health information for international travel, 1992. Atlanta: US Department of Health and Human Services, Public Health Service, 1992; DHHS publication no. (CDC)92-8280.

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