Diagnosis and treatment of cholera in the United States: Are we prepared?

Objective. - To assess cholera recognition and treatment by US health care workers in the largest cholera outbreak in the United States this century. Design. - We reviewed the medical records of passengers from a flight on which a cholera outbreak occurred. To determine the availability of oral rehydration solutions, we surveyed treatment facilities and referral pharmacies. Setting. - On February 14, 1992, more than 100 passengers on a flight from South America to Los Angeles, Calif, were infected with toxigenic Vibrio cholerae O1. Subjects. - Fifty-four of 67 passengers who sought care in California and Nevada. Results. - We reviewed the records of 54 passengers, including 39 with diarrhea and 15 without symptoms. All 17 persons who sought treatment before the outbreak was widely reported by the media had diarrhea. For 12 of these persons, recent travel to South America was noted, but only those four whose records listed cholera as a possible diagnosis were immediately hospitalized. Seven sought care again within 3 days; three were dehydrated, two of these three were hospitalized, and one of these two died. None of the 26 patients suspected to have cholera received appropriate fluids; severely dehydrated patients did not receive Ringer's lactate solution and those not severely dehydrated did not receive an oral rehydration solution. None of the facilities and pharmacies involved stocked World Health Organization oral rehydration salts solution, the preferred solution for treating cholera and other diarrheal diseases. Conclusions. - Treatment of cholera in the United States was suboptimal. Oral fluids appropriate for the treatment of cholera and other diarrheal diseases were generally unavailable. Widespread cholera in the developing world means that US physicians should be prepared to treat 'imported' cases. Physicians evaluating patients with diarrhea should obtain a travel history, should consider cholera in patients returning from countries with endemic or epidemic cholera, and should instruct patients in appropriate use of World Health Organization oral rehydration salts solution or other oral rehydration solutions containing 75 to 90 mmol/L of sodium. Pharmacies and medical facilities should stock these solutions.