Transmission of cholera is faecal-oral, via contaminated food or water.

Transmission through other means (insects, contaminated articles, person-to-person) is considered unusual, or to occur only under special circumstances.

It is therefore important to refer to WHO recommendations for international travellers from cholera-infected areas.

As stated in WHO’s annual publication "International Travel and Health", vaccination against cholera cannot prevent the introduction of the infection into a country. Therefore although cholera vaccines exist, cholera vaccination should not be required of any traveller.

Also, WHO does not recommend travel or trade restrictions between countries when a country is affected by cholera, as these do not prevent the spread of cholera and instead divert resources better used for other purposes. However, any traveller with symptoms suggestive of cholera should seek medical attention.
On occasion, national authorities have provided a card to travellers arriving from a cholera-infected area advising them to do so.

Against that background and considering the previous extensive international and Pacific experience, the primary recommendation is to strengthen surveillance activities (passive and active) for

diarrheal diseases, and be prepared to implement control activities as soon as cholera is suspected.

Clinicians should immediately report "any patient aged 5 years or more with severe dehydration from acute diarrhea (with or without vomiting)", i.e. any case suspected of cholera, and this case must be properly and urgently investigated. There should also be monitoring (at least weekly, or daily if suspect cases do occur) of acute diarrhea cases of any type with appropriate case investigation carried out if unusual increase presents. Provided appropriate resources exist—human and communication—surveillance systems should shift from passive reporting to active surveillance for better timeliness, i.e.: information is actively collected (by phone, radio or visits) by contacting all reporting clinicians in the health facilities around the State.

Preparedness includes:

• proper stocks of ORS and IV fluids and equipment for rehydration (IV fluids being the most challenging in terms of logistics knowing the quantities needed for treating a cholera case), antibiotics active against cholera (doxycycline or tetracycline, trimethoprim-sulfamethoxazole, erythromycin), chlorine and disinfectant.
  For the sake of patient’s comfort and logistic management of the outbreak, it is important to remind that ALL patients with moderate dehydration should primarily be given ORS rather that IV fluids. Rehydration by way of drinking ORS, when feasible, allowing an efficient, far more comfortable, easier and safer case management than IV fluids.

• water for domestic use chlorinated or boiled (vigorous rolling boil for 1 minute), and water supply systems assessed for safety.

• facilities for sanitary human waste disposal in the communities.

• training of health personnel (clinical and lab investigation, case management, preventive measures).

• health education/awareness activities carried out to the communities, starting with the basic "cook it, peel it or leave it !"

• identifying a laboratory able to undertake rapid confirmation of the organism at the beginning of the epidemic if possible ( for further information, see contacts below )
   
• ensure that proper stocks of Cary-Blaire media are available for laboratory samples transportation.

Dr Tom Kiedrzynski at SPC Noumea