Ask the Experts: Cholera

Results (10)

The FDA-licensed cholera vaccine CVD 103-HgR (Vaxchora, by Emergent BioSolutions) is currently unavailable in the United States. The manufacturer temporarily halted production in December 2020. CDC published ACIP recommendations for its use in September 2022, available at www.cdc.gov/mmwr/volumes/71/rr/rr7102a1.htm.

CVD 103-HgR is recommended for travelers ages 2–64 years old going to areas of active toxigenic Vibrio cholerae O1 transmission. Criteria for “active” cholera transmission for a given country and a table classifying countries according to transmission levels are found at wwwnc.cdc.gov/travel/page/cholera-travel-information.

Vaccination against cholera is not routinely recommended because cholera is rare in travelers and most travelers do not visit areas of active transmission. However, disease is more likely to occur in travelers who may have limited access to safe food and water in outbreak settings, including outbreak response workers. Clinicians should consider these factors in addition to the level of cholera transmission in the destination country, length of stay, patient’s age and history of pre-existing medical conditions, and the availability of intravenous hydration when assessing a traveler’s risk for cholera infection and the need for vaccination. Other WHO-prequalified cholera vaccines not licensed in the United States may be available in the destination country.

All travelers to cholera-affected areas should follow safe food and water precautions and proper sanitation and personal hygiene measures as primary prevention strategies against cholera infection. Travelers who develop severe diarrhea should promptly seek medical attention for rehydration therapy.

Last reviewed: August 21, 2023

Other oral cholera vaccines have been prequalified by the World Health Organization (WHO). These vaccines are not available in the United States and ACIP has not provided recommendations on use of these vaccines. To learn more about these vaccines, visit the World Health Organization Cholera Vaccines page: www.who.int/news-room/fact-sheets/detail/cholera.

For further information from CDC about cholera vaccines and preventing cholera, visit www.cdc.gov/cholera/vaccines.html and wwwnc.cdc.gov/travel/page/cholera-travel-information.

Last reviewed: August 21, 2023

ACIP has not made recommendation related to revaccination or booster doses with the FDA-licensed oral cholera vaccine, CVD 103-HgR. As more information becomes available, CDC will update its recommendations accordingly.

Last reviewed: August 21, 2023

With one exception, you do not need to consider the timing of this vaccine relative to other vaccines. According to CDC’s “General Best Practice Guidelines for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. The one exception is administration of Ty21a oral typhoid vaccine and oral cholera vaccine. The CVD 103-HgR buffer might interfere with the enteric-coated Ty21a formulation. For this reason, ACIP recommends that the cholera vaccine should be administered at least 8 hours before ingesting the first dose of Ty21a vaccine.

Last reviewed: August 21, 2023

Antibiotics administered before or after receiving the CVD 103-HgR vaccine might diminish the effectiveness of the vaccine because the immune response to the vaccine relies on the live attenuated vaccine organisms replicating within the small intestine. We do not know what the optimal interval is between receipt of antibiotics and the Vaxchora vaccine. CDC refers clinicians to the package insert which specifies that CVD 103-HgR should not be given to patients who have received oral or parenteral antibiotics during the preceding 14 days. A duration of fewer than 14 days between stopping antibiotics and giving CVD 103-HgR might be acceptable under certain circumstances, such as if travel cannot be avoided during that 14-day interval.

The package insert, however, does not specify an optimal minimum duration between the completion of CVD 103-HgR vaccination and starting antibiotics. In certain circumstances, antibiotics might be clinically necessary after the vaccine (to treat an unrelated infection), thus clinical discretion is recommended.

Last reviewed: August 21, 2023

Chloroquine might diminish the immune response to CVD 103-HgR. The vaccine manufacturer, Emergent BioSolutions, recommends that CVD 103-HgR be administered 10 days or more before starting chloroquine. Doxycycline, a tetracycline antibiotic, is often used for malaria prophylaxis. The manufacturer does not recommend administration of the vaccine with oral antibiotics and does not recommend administering CVD 103-HgR to a person within 14 days prior to vaccination. The optimal duration between completion of CVD 103-HgR and then starting doxycycline is unknown.

Last reviewed: August 21, 2023

Two or more injectable or nasally administered live vaccines not administered on the same day should be separated by at least 4 weeks to minimize the potential risk for interference. If two such vaccines are separated by less than 4 weeks, the second vaccine administered should not be counted and the dose should be repeated at least 4 weeks later. Alternatively, one can perform serologic testing to check for immunity, but this option may be more costly, may not be practical if multiple antigens are involved (such as measles, mumps and rubella), and may provide results that are difficult to interpret.

In cases where the vaccine doses given less than 28 days apart are two doses of the same live vaccine in a series (e.g., 2 doses of MMR vaccine), not different vaccines, you do not need to repeat the second dose if it was inadvertently administered within the 4-day “grace period” before day 28. If given more than 4 days earlier than day 28, the second dose should be repeated after the recommended minimum interval from the invalid dose.

The oral vaccines Ty21a typhoid, cholera and rotavirus vaccines can be administered on the same day with or at any interval before or after other live vaccines (injectable or intranasal). However, ACIP recommends that oral cholera vaccine should be administered before Ty21a vaccine, and at least 8 hours should separate the oral cholera vaccine and the first dose of Ty21a in order to minimize the risk that the oral cholera vaccine buffer might interfere with the enteric coating of the oral Ty21a vaccine.

Last reviewed: June 6, 2023

In general, no. According to ACIP’s “General Best Practice Guidelines for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. So, live oral cholera vaccine may be administered simultaneously with another vaccine, or at any interval before or after administration of another vaccine. There is one exception: ACIP recommends (based upon expert opinion) that live oral cholera vaccine should be administered at least 8 hours before the first dose of live oral Ty21a typhoid vaccine in order to minimize the risk that the oral cholera vaccine buffer might interfere with the enteric coating of the oral Ty21a vaccine.

Last reviewed: June 6, 2023

Immunity is not considered lifetime, however, CDC does not currently have any recommendation related to revaccination with oral cholera vaccine. The duration of immunity beyond the 3-month period of clinical trial evaluation in people age 18 through 45 years following one dose is unknown. As more information becomes available, CDC will update its recommendations accordingly.

Last reviewed: June 6, 2023

In general, no. According to ACIP’s “General Best Practice Guidelines for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. So live oral cholera vaccine may be administered simultaneously or at any interval before or after administration of most other vaccines. One exception is Ty21a oral typhoid vaccine (Vivotif, Emergent Travel Health) and oral cholera vaccine. Oral cholera vaccine should be administered before Ty21a vaccine, and at least 8 hours should separate the cholera vaccine and the first dose of Ty21a.

Last reviewed: December 28, 2022

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