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Red Book updated with recommendations for use of cholera vaccine in children

December 2, 2022

The cholera chapter of the AAP Red Book has been updated to include recommendations for use of a vaccine in children ages 2-18 years who are traveling to areas with active transmission.

CVD 103-HgR (Vaxchora) is a live-attenuated strain of Vibrio cholerae O1 given orally as a single dose. In 2016, it was approved by the Food and Drug Administration and recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) for adults ages 18-64 years.

In December 2020, the FDA expanded use of the vaccine to include children ages 2-17 years based on data from pediatric trials that demonstrated safety and immunogenicity. ACIP voted in February 2022 to recommend CVD 103-HgR for prevention of cholera among travelers ages 2-64 years to an area with active cholera transmission. The AAP endorses this recommendation.

Cholera is a potentially life-threatening disease caused by toxin-producing strains of V. cholerae. Infection causes acute, watery diarrhea that can lead to severe dehydration. Without prompt rehydration, cholera can be fatal within hours of symptom onset. Cholera usually occurs as the result of ingestion of contaminated food or water. Individuals, including children from areas where cholera is infrequent, may be exposed during travel to areas of active transmission, including areas with endemic (ongoing) transmission and those with current or recent outbreaks.

The CDC has identified a global increase of cholera infections, with large outbreaks occurring in Haiti, Malawi and Syria. Currently, the CDC considers 25 countries to have active cholera transmission. In addition, eight travelers with cholera have returned to the United States from Pakistan, Iraq and Bangladesh in 2022.

CVD 103-HgR should be given 10 or more days prior to travel, requires reconstitution of a buffer solution with bottled or spring water and may be given with certain sweeteners (stevia or sucrose) to enhance palatability. Details regarding administration, compatibility with other medications and potential contraindications are available in the CVD 103-HgR package insert.

Hygienic practices also are encouraged to prevent travel-associated cholera.

The CVD 103-HgR manufacturer paused production in 2020 as a result of decreased demand due to the COVID-19 pandemic, and the vaccine currently is unavailable. Information on shortages is available at

Dr. Ratner is a member of the AAP Committee on Infectious Diseases.


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