#108 Tools for Stools: Oral Cholera Vaccine for Travelers’ Diarrhea Prophylaxis
CLINICAL QUESTION
Should oral cholera vaccine (DukoralTM) be routinely recommended to prevent travelers’ diarrhea (TD)?
BOTTOM LINE
Randomized Controlled Trials (RCT) evaluating Dukoral™ for TD did not show a benefit and routine use is not recommended.
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EVIDENCE
Systematic review of 24 RCTs of vaccines to prevent TD.1 Many tested vaccines in cholera endemic areas (not travelers) and examined immunologic (not clinical) outcomes.
- RCT of 502 US college students, given oral cholera vaccine or placebo upon arrival in Mexico, with a second dose ten days later found no difference in:2
- Diarrhea (any cause): vaccine 51%, placebo 49%.
- Enterotoxigenic E. coli (ETEC) diarrhea: vaccine 14%, placebo 15%.
- Diarrhea was reduced ≥7 days after second dose, but this was not confirmed by external re-analysis.1
- Adverse events: not reported.
- RCT of 187 travelers comparing ETEC vaccine, oral cholera vaccine, and placebo (given at least seven days before leaving) found:3
- No significant difference between groups in all-cause diarrhea.
- Placebo 21%, ETEC vaccine 24%, oral cholera vaccine 27%.
- No significant difference between groups in all-cause diarrhea.
- Diarrhea, usually from ETEC, affects up to 50% of travelers to developing countries.4-6
- Risk of cholera is ~1/10,000 to 1/million per month abroad.7
- Cholera toxin subunit in vaccine triggers cross-immunity to ETEC8 leading to its indication for prevention of TD.9
- Most cases of TD resolve spontaneously in 3–4 days,5 but taking antibiotics at onset improves 72 hour cure (84% vs. 50%, Number Needed to Treat 3).10
- North American guidelines do not recommend oral cholera vaccine for majority of travelers.4,5
- Vaccine costs ~$90; not covered by any provincial health care plans.
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