Cholera is an acute diarrhoeal infection caused by Vibrio cholerae, spread through water and food contaminated with faeces. The World Health Organization has reported a sustained global upsurge since 2021, with outbreaks across Africa, the Middle East and Asia, often linked to conflict, flooding and poor sanitation. Nigeria, Sudan, the Democratic Republic of the Congo, Ethiopia and Afghanistan are among the countries that have reported large outbreaks.
Cholera can kill a healthy adult within hours through severe dehydration. But WHO notes that with prompt and appropriate rehydration, the case fatality rate should stay below 1%. Nurses deliver almost all of that rehydration.
Recognising cholera
- Sudden onset of profuse, painless, watery diarrhoea, often described as “rice-water stool” (pale, cloudy, with flecks of mucus).
- Vomiting is common.
- Usually little or no fever.
- Rapid dehydration, leg cramps (from electrolyte loss), and in severe cases, shock.
During an outbreak, anyone with acute watery diarrhoea should be managed as a suspected case. Rapid diagnostic tests are used for surveillance, with stool culture or PCR to confirm.
Assess dehydration
| Sign | No dehydration | Some dehydration | Severe dehydration |
|---|---|---|---|
| General condition | Well, alert | Restless, irritable | Lethargic or unconscious |
| Eyes | Normal | Sunken | Sunken |
| Thirst | Drinks normally | Thirsty, drinks eagerly | Drinks poorly or unable to drink |
| Skin pinch | Goes back quickly | Goes back slowly | Goes back very slowly (more than 2 seconds) |
| Pulse | Normal | Fast | Weak or absent |
| Treatment | Plan A | Plan B | Plan C |
Plan A: no dehydration
- Give oral rehydration solution (ORS) after each loose stool, to replace losses, and send home with ORS sachets.
- As a guide: children under 2 years about 50–100 mL after each stool; 2–10 years about 100–200 mL; older children and adults as much as they want.
- Continue breastfeeding and normal food.
- Teach danger signs: the patient should return immediately if diarrhoea worsens, they vomit repeatedly, can’t drink, or become very thirsty or drowsy.
Plan B: some dehydration
- Give ORS 75 mL/kg over 4 hours in the health facility.
- Give small, frequent sips by cup or spoon. If the patient vomits, wait 10 minutes, then continue more slowly.
- Reassess after 4 hours, and reclassify.
Plan C: severe dehydration
This is an emergency. Give IV fluids immediately, preferably Ringer’s lactate (Hartmann’s), or 0.9% sodium chloride if not available. The WHO-recommended total is 100 mL/kg:
| Age | First 30 mL/kg in | Then 70 mL/kg in |
|---|---|---|
| Infants under 12 months | 1 hour | 5 hours |
| Over 12 months (including adults) | 30 minutes | 2½ hours |
- Use a large-bore cannula, and a second line if needed. For an adult, this means several litres in the first hours. Squeezing bags and running two lines is often necessary.
- Start ORS (about 5 mL/kg/hr) as soon as the patient can drink.
- Reassess every 15–30 minutes until a strong radial pulse returns, then every 1–2 hours.
- Children with severe acute malnutrition need a different, slower approach. Follow the specialist protocol.
Antibiotics and zinc
- Antibiotics (commonly a single dose of doxycycline, or azithromycin for children and pregnant women, per national guidance) are recommended for severely dehydrated patients and reduce the volume and duration of diarrhoea. They are not a substitute for rehydration.
- Zinc supplements for children under 5 for 10–14 days reduce the duration and severity of diarrhoea.
Nursing in a cholera treatment centre
- Cholera beds (cots with a hole and a bucket underneath) allow you to measure stool volume and keep patients clean.
- Keep a simple input and output chart for each patient.
- Watch for fluid overload (puffy eyes, breathlessness) as well as continuing losses.
- Watch for hypoglycaemia in children and low potassium (weakness, abdominal distension).
- Discharge criteria commonly include: able to drink ORS, no vomiting, passing urine, and stools no longer liquid or much reduced.
Infection prevention
- Hand hygiene with soap and water (or alcohol rub) at every contact.
- Gloves and aprons for contact with stool or vomit; boots in the treatment area.
- Disinfect stool and vomit with chlorine solution before disposal, and use the correct chlorine strengths for hands, surfaces and linen as set by your treatment centre.
- Footbaths or foot sprays at the entrance and exit.
- Teach families about safe water (boiling, chlorination), safe food handling and safe burial practices.
Vaccines
Oral cholera vaccines are used in outbreak responses and high-risk areas, coordinated through the International Coordinating Group on Vaccine Provision. Global supplies have been very tight in recent years, so WHO has recommended single-dose campaigns during outbreaks. Vaccination supports, but does not replace, clean water and sanitation.
Related: IV fluids guide · Drip rate calculations · Hand hygiene
Based on WHO cholera fact sheets and the Global Task Force on Cholera Control guidance on case management. Educational content: follow your national cholera guidelines.