The Alarming Rise of Silent Heart Attacks in Young Adults

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Recently, there's been a shocking trend: seemingly healthy young adults—typically in their 20s, 30s, and 40s—suddenly dropping from heart attacks. Exercising at the gym, dancing, or simply running errands on a weekday afternoon, these unexpected events are raising frantic questions. What's going on? Why are heart attacks—especially silent heart attacks—on the rise in young adults?

What Is a Silent Heart Attack?

A silent heart attack is exactly that: a heart attack without the usual warning symptoms of crushing chest pain. Explains Dr. Niranjan Hairman, a Delhi cardiologist, these silent heart attacks remain undetected until late. Most individuals go about their daily lives without knowing that their heart has already begun to get damaged.

An Increasing Issue Among the Young

Dr. Hairman describes how this is on the increase in India, particularly among those in their 30s and 40s. "They look fit and healthy," he relates, "but suddenly collapse and are rushed into the hospital." It's a frightening reminder that all may not be as it appears.

Who Is at Risk?

Silent heart attacks are very common among:

• Women
• Those with diabetes
• History of heart disease in family

Silent heart attacks happen in 22% to 60% of all heart attacks globally. Slowly they can ruin the heart muscle, and because the signs are minor or confused with common discomforts—like indigestion or tiredness—they're usually ignored.

Frequently Missed Symptoms

Warning signs are mistaken for everyday discomforts by most people due to their familiarity. Dr. Hairman warns that these could be symptoms of a silent heart attack in reality:

• Mild chest pain
• Indigestion or gassy-type symptoms
• Pain in the neck, arm, or jaw
• Unusual tiredness or breathlessness
• Dizziness or faintness

If these symptoms persist on a regular basis, don't take matters into your own hands. Consult a doctor.

Lifestyle Factors That Increase the Risk

Fast-paced modern lifestyles are not entirely to blame. Here's what Dr. Hairman recognizes as main risk factors:

• Stress
• Poor sleep (fewer than 7–8 hours a night)
• High-intensity exercise without adequate preparation
• Unhealthy eating habits, especially processed or fatty foods
• No health checkups every year

He also claims that genetics play a role in the vulnerability of Indians to cardiovascular conditions. Indians, for instance, are more susceptible to heart disease due to their smaller arteries, increased body fat, and propensity towards diabetes.

How to Keep Yourself Safe

1. Get Regular Health Checkups

Everyone—especially those with a family history of heart problems—should undergo a full physical examination at least once a year. Key tests include:

• ECG
• Cholesterol levels
• Blood pressure
• Blood sugar levels

2. Don't Skip Sleep

Make quality sleep a priority. Aim for 7–8 hours a night, and take chronic fatigue seriously—even if you’re sleeping enough. Persistent tiredness may be a red flag.

3. Ease Into Exercise

Before starting on any strenuous exercise program, get a physical examination. Don't jump into heavy gym workouts without expert counsel. Slow progress is safer and more sustainable.

4. Mind Your Diet

Avoid processed, high-sugar, high-fat foods. Focus on fresh whole food and drink water. If a member of your family has had a heart attack, these food changes are especially important.

5. Keep Stress in Check

Make time in your day for daily stress-relief activities like yoga, meditation, or walking. Chronic stress puts your heart to the test over the long haul.

Final Thoughts: Don't Ignore the Signs

Silent heart attacks are known as "silent killers" for a reason—suddenly, they strike without customary symptoms and can cause permanent damage or sudden death. No matter how young, healthy, and fit someone appears, they can still be susceptible.

Pay attention to your body. If something doesn't feel right, don't ignore it. Early discovery and changing one's lifestyle can save a life.

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6 Science-Backed Steps to Prevent Dementia Early and Improve Brain Health

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This site contains Amazon affiliate links. I am an Amazon Associate and I do receive commissions from purchases made using my links. What this means is that when you click on a link and shop, I may get a small commission paid to me at no extra charge to you. Thank you ever so much!

Learn about six expert-recommended lifestyle changes that can prevent dementia, Alzheimer's, and cognitive decline—beginning at age 30. How sleep, diet, and supplements like NAD+ may protect your brain health.

Why Preventing Dementia Begins Earlier Than You Realize

Dementia, Alzheimer's, and other neurodegenerative diseases don't all of a sudden descend upon your 60s or 70s. Some of the earliest modifications in the brain occur in your 20s and 30s, according to new research. This is why experts now recommend the ideal time to start preventing dementia is decades before symptoms begin.

If you've ever wondered how to stay sharp, slow cognitive aging, and ward off neurodegenerative disorders, the good news is that lifestyle modifications made now can have a big impact on your brain health in the future.

What Is the SHIELD Method for Brain Health?

Dr. Rudolph Tanzi, the director of Alzheimer's and neurodegenerative disease research at Massachusetts General Hospital, developed a science-backed method to develop long-lasting brain health. His SHIELD approach is comprised of six habits to adopt daily that have been found to lower the risk for dementia and enhance mental clarity.

Here's the breakdown:

1. S = Sleep: Get Deep, Restful Sleep

Sleep 7–8 hours a night to eliminate brain plaque linked to Alzheimer's.

Power naps also improve memory and cognitive function.

Poor sleep increases your risk of dementia and decreases brain resilience.

2. H = Handle Stress: Reduce Cortisol, Boost Brain Function

Chronic stress accelerates brain aging and increases inflammation.

Meditation can decrease stress hormones and lower cognitive errors by 25%.

Regular mindfulness improves concentration, memory, and emotional control.

3. I = Interact with Friends: Stay Socially Connected

Loneliness doubles your risk for dementia and cognitive decline.

Positive social relationships stimulate brain plasticity and protect gray matter.

Online and offline daily interaction keeps your brain engaged.

Action Step: Call a friend, learn a class, or join community groups. 

4. E = Exercise: Move Your Body, Grow Your Brain

Exercise increases blood flow and stimulates the development of new brain cells.

Helps to dislodge amyloid plaques linked with Alzheimer's.

Try to get at least 150 minutes a week of moderate exercise.

Start small—walking, dancing, yoga, or weight training are all effective.

5. L = Learn New Things: Challenge Your Mind

Learning builds new neural connections (synapses) that protect against dementia.

Novelty—like learning a new language or a course—increases brain flexibility.

More synapses = more memory repositories = reduced risk of cognitive decline.

Swap brain games for real learning experiences or creative activities.

6. D = Diet: Nourish Your Brain With Healthy Food

The Mediterranean diet is optimal for brain well-being: fruits, vegetables, fish, and whole grains.

Avoid too much sugar, red meat, and processed foods.

Brain health is gut health—fiber and probiotics matter.

Don't forget to eat B vitamin-rich foods like eggs, fish, and leafy greens.

BONUS: The NAD+ Connection—Support Your Brain at the Cellular Level

Another new strategy in brain longevity science is maintaining healthy NAD+ (nicotinamide adenine dinucleotide) levels—coenzyme essential for energy, DNA repair, and protecting brain cells.

Dr. Andrew Shao, a well-known nutritional biochemist, explains

NAD+ declines with age, starting in your 30s, due to stress, poor diet, alcohol, and pollution.

Less NAD+ = fewer cellular repairs = higher risk of brain disease.

Nicotinamide riboside (NR), a B3 vitamin, can boost NAD+ by up to 150%.

Taking 1,000 mg of Niagen® NR daily might help with brain energy, metabolism, and suppress neuroinflammation—especially as you age.

Act Now: Stop Cognitive Decline Before It's Too Late

You don't have to wait until your golden years to take care of your brain. With the SHIELD method and the help of NAD+, you can begin building long-term brain resilience today.

✅ Summary: 6 Evidence-Based Strategies to Prevent Dementia Naturally

Sleep at least 7–8 hours each night

Use meditation and mindfulness to manage stress

Stay socially active

Exercise regularly (150 minutes/week)

Keep learning new things

Eat a brain-smart Mediterranean diet

Supplement with NAD+ support via nicotinamide riboside

Hungry for More Brain Health and Longevity Advice?

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Why Building Muscle Is Important at Every Age: 7 Benefits You Need to Know

Affiliate Disclosure

This site contains Amazon affiliate links. I am an Amazon Associate and I do receive commissions from purchases made using my links. What this means is that when you click on a link and shop, I may get a small commission paid to me at no extra charge to you. Thank you ever so much!

When the average person hears "muscle," he or she thinks of bodybuilders posing in the gym or athletes pushing through heavy training sessions. But the history of muscle health has changed—and it's no longer just for the fitness enthusiast.

In the last couple of decades, science has made it painfully obvious: building muscle mass isn't solely about appearance or sports performance. It's now understood to be one of the most crucial tools for sustaining long-term health no matter your age or level of fitness. From making mobility a breeze to protecting against chronic disease, muscle mass is the key to overall health.

Whether you're 20 or 70, here are seven key benefits of possessing and keeping muscle mass—along with plans to begin with.

1. You'll Get Stronger and More Functional in Your Daily Life

Yes, strength comes in handy in the gym—but the sorcery begins when it carries over into your daily life."When you build muscle, you get stronger. But this isn't necessarily about deadlifting a car or flexing at the beach," says certified personal trainer Anthony Moreno. 

"It's about grocery shopping without sweating, lifting your kid without aggravating your back, or rearranging furniture without calling three friends."

Simple and plain: muscle gives you the ability to live life on your own terms.

2. You'll Reduce Your Risk of Injury

Bigger muscles translate to better support for your joints, better posture, and safer movement patterns—all of which help prevent injury.

"Muscle gain stabilizes the joints, prevents injuries, and contributes to longevity through functional independence," explains clinical exercise physiologist Brian Betancourt.

That said, if you're just starting out with strength training, don't be in such a hurry. Prioritize proper form and allow your body to adjust. Doing too much too quickly is actually more likely to create issues than it is to solve them.

3. You'll Help Regulate Blood Sugar Better

Muscle is one of the body's main glucose-handling centers. In fact, up to 80% of the glucose you eat is taken in by your muscles.

That means the more muscle you have, the more efficiently your body will regulate blood sugar—whether you're trying to avoid type 2 diabetes or manage/maintain a diagnosis.

Plus, your muscles can absorb glucose even without insulin during and after exercise, helping to keep your blood sugar levels steady throughout the day.

4. You’ll Boost Your Metabolism

Muscle isn't just for strength—it’s a metabolic powerhouse.

Having more muscle boosts your resting metabolic rate (RMR), or the rate at which your body expends calories while at rest. Though muscle doesn't burn calories with the intensity of a blast furnace, it burns more than fat—6–7 calories per pound of muscle tissue per day, vs. only 1–2 for fat.

Better still? Following a strength training exercise, your metabolism remains in overdrive for a full 48–72 hours.

As physical therapist Hiral Jain Surana describes it, "Muscle enhances your metabolic flexibility—your capacity to alternate between burning carbs and fat for fuel—which assists in energy control and long-term weight regulation."

5. You'll Feel More Confident—Inside and Out

Building muscle is not just about the physical body—it is incredibly empowering. 

"When you set yourself to gaining muscle, you acquire discipline, grit and faith in yourself," personal trainer Milchu Perez explains. "You demonstrate to yourself that you can achieve tough things."

And science backs this up. Studies show that people who strength train report higher self-esteem, better mood, and improved body image—regardless of age.

“I’ve seen clients find strength they didn’t know they had—not just in their bodies, but in their minds,” says trainer Eddie Lester. “It helps them through tough times, and the confidence spills over into every area of life.”

6. You’ll Strengthen Your Bones, Too

Muscle and bone are a package deal. When you build muscle, you also increase bone mineral density, which is important in the prevention of osteoporosis and osteopenia.

"Strength training stresses your bones, and that's good," Surana says. "That stress signals your body to strengthen them, which can lower the risk of fracture, arthritis pain, and instability."

Consider muscle your bones' best buddy. They support and protect each other—and assist you in moving around safely.

7. You'll Age with Strength and Independence

Muscle is perhaps the greatest predictor of how we will age. Aside from lifespan, muscle drives health-span—years lived in good health.

"Your quality of life with age is tied to muscle health," says trainer Keri Howell. "The more muscle, the fewer falls, the better the mobility, the faster the recovery from sickness, and the healthier the brain."

It even raises the chances of survival when you are critically ill. Bottom line: build muscle now and remain active, capable and independent well into old age.

“Want to keep hiking, climbing stairs or even just getting off the toilet without help in your 70s?” asks Moreno. “Build muscle now.”

How to Start Building Muscle—At Any Age

Ready to reap the benefits of more muscle? Here’s how to begin:

1. Strength Train 2–3 Times a Week: Focus on major muscle groups (legs, back, chest, arms, core). Bodyweight exercises are great if you’re starting out.
2. Eat Enough Protein: 0.54–1.0 grams of protein per pound of body weight daily (1.2–2.2 g/kg/day).
3. Don't Rush: Building muscle is a slow process. Track your improvement in strength or feel—but not merely what you're seeing in the mirror.
4. Form Over Weight: Stress proper technique before increasing more reps or resistance.
5. Sleep 7–9 Hours of Sleep Each Night: Recovery is when muscle growth occurs—don't miss it.
6. Feed with Adequate Calories and Carbs: Your body requires fuel in order to build new muscle.

Last Thoughts

Muscle is more than muscle—it's strength, health, confidence, and freedom. Regardless of age or fitness level, it's never too late (or too early) to begin building it.

So grab those dumbbells, roll out the mat, or simply get your body moving. Your future self will appreciate it.

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Understanding Pain: More Than Just a Feeling

For many of the world's millions, pain is not an occasional inconvenience—it's a daily sidekick. From pounding headaches and arthritis pain to slicing nerve pain, much of the world lives with pain every day. While we all experience pain, we do not all experience it the same.

Pain is highly individualized. Others may wince at the slightest bump, whereas others don't even flinch from a rough tumble. It has nothing to do with weakness or strength—nor science. Pain is more than just a bodily sensation, according to Professor Bart Morlion, an international expert in pain medicine at KU Leuven Cancer Institute in Belgium. Speaking in Nairobi last week when inaugurating the Haleon Pain Management Institute, Prof Morlion observed that pain is a biopsychosocial phenomenon—not only our bodies, but also our mood, mindset, and environment.

"We don't yet have tools to measure pain objectively. We rely on patients to report to us how they feel—from 0 to 10," he said.

While subjective, that pain scale remains the gold standard in practice. It is also a reminder that no two people experience pain in exactly the same way.

Why Do Some People Tolerate Pain Better?

While our pain threshold—when we begin to experience pain—is quite consistent in individuals, pain tolerance varies greatly. Attitude, psychological resilience, life history, and even cultural heritage are all conditions that decide how much pain we can withstand.

This delicate dance between body and brain also explains why two individuals with the same injury will rate pain by orders of magnitude differently.

How Painkillers Actually Work

We all grab for painkillers when we hurt. But what exactly happens when you pop a pill?

Different drugs affect different parts of the pain process:

• Paracetamol reduces the brain's feeling of pain.
• NSAIDs (e.g., ibuprofen or diclofenac) cut down inflammation, a cause of pain.
• Opioids (e.g., morphine) switch on the brain's own pain-killing systems.

Briefly, some drugs turn off the pain signal, others block out pain, and others do both. But, as beneficial as they are, these drugs are not without danger.

Paracetamol is generally safe—but high doses damage the liver.

NSAIDs lead to stomach ulcers, kidney problems, and increased heart risk, especially among older individuals.

Opioids, though powerful, carry a risk of dependence—even for those who have totally no history of addiction. "There is a risk of around 8% that patients may become dependent, perhaps within as few as a few weeks," cautions Prof Morlion.

Acute pain serves a purpose—it warns us that something's wrong. But when pain persists after the healing of the initial injury, it becomes chronic. This can occur if the nervous system becomes hypersensitive, a situation known as central sensitization. Pain is then the disease itself.

Sudden withdrawal from pain medication also produces rebound pain, an intensified return of symptoms, especially common with the use of NSAIDs in diseases such as arthritis.

And some pain syndromes, like fibromyalgia, are unseen but hellish. Without overt harm or inflammation, patients hurt all over and are tender to the touch due to an oversensitive nervous system. It is a disorder that disproportionately afflicts women and is commonly misdiagnosed or dismissed. 

The Mind-Body Connection

While medication is a key component, psychological techniques could also influence the way we feel pain. Techniques such as breathing exercises, guided meditation, and distraction strategies can all be employed to instruct the brain to dial down its pain response.

"The brain is a very powerful tool," Prof Morlion says. "With the right methods, we can instruct it to register less pain."

This's not about denying pain or "toughing it out" but about utilizing all available approaches, from medication to mindfulness, to maximize quality of life.

Pain Isn't Just a Symptom—It's an Experience

Reminding us of something important, Prof Morlion says, "Pain is more than just a symptom. It's an experience that affects your body, mind, and quality of life."

By embracing a biopsychosocial model of care, healthcare providers can move beyond just treating symptoms. They can help people truly heal—body and mind.

If you’re living with pain, know this: you’re not alone, and help is evolving. The future of pain care lies not just in pills, but in compassion, understanding, and a full-spectrum approach that puts patients first.

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Your OB-GYN Wants You to Stop Doing These 6 Things

Taking care of your reproductive health often comes down to a few widely shared rules—pee after sex, ditch damp clothes ASAP, don’t douche. But OB-GYNs say there are other, lesser-known habits that could be quietly affecting your vaginal health and causing long-term issues.

Here are six common habits gynecologists wish more women would drop—and clever substitutions for protecting your comfort and general health.

1. Ignoring Strange or Heavy Periods

You might assume spotting or super-heavy periods are just "your normal," if your sister or mother experienced the same. But strange bleeding or periods so heavy they disrupt your life can be a sign of something going wrong.

"Any sort of bleeding that takes over your life or occurs at strange intervals shouldn't become the new normal," says Christine Carlan Greves, MD, a board-certified ob-gyn with Orlando Health.

Irregular bleeding can be triggered by hormonal disorders, fibroids, polyps, thyroid disease, or even (in some cases) gynecologic cancers.

✔️ What to do:

Don't wait it out. If your period changes all of a sudden, is unusually painful, or is accompanied by spotting between cycles, see your ob-gyn.

2. Not Tracking Your Menstrual Cycle

If your period shows up right on time, you may not think it's worth tracking. If it's always unpredictable, you may think tracking won't help. But either way, your cycle can be a vital sign of your health.

"Menses are a good indicator of overall health," states Christie Cobb, MD, an ob-gyn based in Arkansas.

Tracking can also identify issues like PCOS, thyroid condition, or hormonal imbalance early on.

✔️ What to do:

Track your periods using an app or take notes on your calendar. Track not just dates, but also symptoms like cramps, spotting, or mood swings—it can help your doctor accurately diagnose patterns or changes.

3. Skipping Lube—or Choosing the Wrong Kind

Sex without lube can cause painful friction, especially if you’re on birth control, postpartum, or in menopause. Worse, some popular lubes contain glycerin, a sugar alcohol that can feed yeast and trigger infections.

“Glycerin can increase your risk of a yeast infection,” explains Kate McLean, MD, MPH, chief medical officer at vaginal health company Evvy.

✔️ What to do:

Choose a high-quality, glycerin-free lube—preferably one that’s also free from alcohol, parabens, fragrances, and flavoring.

4. Using “Feminine Hygiene” Products

Despite marketing messages, your vagina doesn’t need help staying clean. In fact, scented soaps, sprays, and wipes can disrupt your pH and kill good bacteria, increasing your risk of irritation and infections.

“The vagina is a self-cleaning organ,” says Renita White, MD, an ob-gyn in Atlanta.

Even your vulva (your outer genital area) needs tender care.

✔️ What to do:

Clean your vulva with plain warm water, or mild, fragrance-free soap if needed. Never put anything inside your vagina—even if it's labeled "freshness" on the package.

5. Leaving a Tampon in Too Long

It’s tempting to stretch tampon use beyond the recommended 4–8 hours—especially when you’re busy or trying to save product. But doing so increases the risk of odor, irritation, or in rare cases, toxic shock syndrome.

✔️ What to do:

Set a phone reminder if needed, and change tampons regularly. For longer wear, consider switching to a menstrual cup, which is safe for up to 12 hours.

Forgot if you took out a tampon? It can't get lost, but it might get stuck further up. Feel gently with clean fingers—or consult your doctor if you're not sure. 

6. Self-Treating Vaginal Symptoms with OTC Creams

Itching or burning "down there" can make you think you can handle it with an over-the-counter antifungal. Unless you know it's a yeast infection (because a doctor used to have the exact same symptoms), treating yourself can drive delays proper treatment.

"Other infections or skin conditions can mimic yeast infections," warns Dr. White.

Some of those mimics include bacterial vaginosis, certain STIs, lichen sclerosis, and even precancerous disorders.

✔️ What to do:

If symptoms are new or persistent, skip the guesswork and see your doctor. OTC creams should only be used if you’ve had a diagnosed yeast infection before and know exactly what you’re dealing with.

Bottom Line

Your reproductive health is more valuable than guessing and assumptions. Tracking changes, choosing the right products, and knowing when to see a doctor can prevent discomfort and catch issues early. These six small habit tweaks might make a big impact in protecting your vaginal health now—and down the road.

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Dementia: The Rising Global Health Crisis You Need to Know

Imagine you being lost on the way home, forgetting common items, or struggling to follow a conversation. For more than 57 million globally, this is existence with dementia. And it's growing—nearly 10 million new diagnoses are made every year.

But dementia is more than forgetfulness—dementia is a complex syndrome that affects the way people think, behave, and relate to one another. Here's what you need to know about this growing health concern.

What Exactly Is Dementia?

Dementia isn't a disease in itself. It's an umbrella term for a group of symptoms that affect memory, problem-solving, language, and mood. It's caused by many diseases and injuries to the brain—Alzheimer's disease being the largest contributor and responsible for 60–70% of cases.

Though it largely affects older individuals, dementia is not a component of regular aging. And indeed, certain people begin to exhibit signs even earlier than age 65—a type known as young onset dementia.

The Warning Signs: When to Take Notice

Dementia usually starts gradually, and symptoms develop over time. Here are some common early warning signs to take notice of:

Forgetting recent events or well-known names

Putting things out of place or getting lost in familiar places

Trouble making decisions or following a conversation

Mood changes like depression, anxiety, or isolation from others

As the disease progresses, individuals will typically need more and more help with daily activities. In late stages, they are unable to recognize their own family members, lose the ability to walk, talk, and feed themselves, and become increasingly personality-changed or hostile.

The Heavy Toll on Families and Society

Dementia cost the global economy a staggering US$1.3 trillion in 2019—and that number is growing. Unpaid care accounts for half these expenditures, typically provided by relatives who work five hours a day on average.

Women are especially affected: not only do they have higher rates of dementia but they also provide 70% of care hours globally.

This disease doesn't just get people—it reconstructs the life of families and communities.

Risk Factors: What's Putting You at Risk?

Although age is the biggest risk factor, there are many more that you can control:

High blood pressure or diabetes

Being overweight or inactive

Smoking and excessive drinking

Social isolation and depression

Air pollution and limited access to education

Staying physically and mentally active, eating a balanced diet, managing chronic conditions, and staying socially active can all help to reduce your risk of dementia.

Can Dementia Be Treated?

There’s currently no cure for dementia, but could improve quality of life with care and treatment. Some medications are able to manage symptoms or slow down worsening, especially in Alzheimer's and vascular dementia.

Supportive care, social activity, and daily activity are just as important. For example:

Keep the brain active through puzzles, hobbies, or new learning
Regular exercise and a healthy diet
Stay in touch with family and friends
Use reminders or apps to assist with everyday activities

Prepare for future care decisions in advance 

Caring for Someone with Dementia

Being a caregiver is both rewarding and exhausting. There are things that must be done:

Get help from family, friends, or professionals

Be part of support groups

Take a break and take care of yourself

Learn stress management techniques like mindfulness or deep breathing

You can't pour from an empty cup—taking care of yourself means taking care of others better. Dementia is one of the biggest health emergencies of our time. It touches on millions of people, redefines families, and places a tremendous strain on caregivers and on the healthcare system. But awareness, early treatment, and support can change everything.

If you or the person you love are feeling the early signs, don't wait—talk to a doctor, contact care networks, and start planning ahead. You're not alone.

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Understanding Cholera: A Threat Still Today

Cholera Overview

Causative Agent

Cholera is toxigenic Vibrio cholerae serogroups O1 and O139 severe enteric infection. Although other serogroups (non-toxigenic O1 and O139 strains) can cause cholera-like disease, only toxigenic O1 and O139 strains result in large outbreaks and are reportable to the World Health Organization (WHO) as "cholera." The pandemic that started in 1961 and currently circulates worldwide is caused by the O1 serogroup. O139, which was once predominant in Asia, is now rarely reported.

V. cholerae O1 occurs in two biotypes—Classical and El Tor—each of three serotypes: Inaba, Ogawa, and Hikojima only infrequently. The El Tor biotype is pan-world and produces milder or asymptomatic infections than Classical. Hybrid strains with traits of both biotypes are now common and may be more virulent.

Transmission

Natural reservoirs of cholera bacteria are fresh and brackish water, usually found in relation to plankton, shellfish, and aquatic vegetation. Infection in man most commonly results from ingestion of contaminated water or food—especially raw or inadequately cooked seafood. Transmission by direct contact with infected individuals or fomites, primarily in hospitals, occurs.

Cholera epidemics are typically caused by poor sanitation, and climatic occurrences like floods or hurricanes. Those who travel with strict hygiene, consume secure food and water, and maintain sanitation measures are at low risk.

Epidemiology

Between 2017 and 2022, the United States diagnosed 39 cases of cholera in recent foreign travelers, primarily from South Asia and Africa. Pakistan, India, and Kenya were the most visited countries. Cases that arose from travel decreased during the COVID-19 pandemic but were seen in higher numbers in 2022. To date, as of 2023, WHO has declared cholera a Grade 3 emergency after outbreaks in over 29 countries.

Cholera continues to be endemic in approximately 50 nations, predominantly in South and Southeast Asia and Africa. Risk is heightened in areas where there is poor access to clean water or sanitation, or in the event of humanitarian emergencies. Persons with decreased stomach acid or blood group O are at greater risk for severe disease.

Clinical Features

Cholera typically causes watery diarrhea (typically "rice water stools") with no fever. Vomiting, nausea, and dehydration quickly follow this. In severe illness, in ~10% of the infections, there can be hypovolemic shock and sudden death if not treated. With prompt rehydration, the mortality is less than 1%.

Diagnosis

Diagnosis in secondary travelers should be provided in acute watery diarrhea with recent history of travel to cholera-endemic areas. Rapid diagnostic tests (RDTs) will detect O1 and O139 antigens but not yield cultures for toxin detection or antibiotic susceptibility testing. Confirmatory testing is by stool culture and by molecular assays such as PCR. Isolates should be submitted to public health laboratories and CDC for full characterization. Cholera is a nationally notifiable condition in the U.S.

Treatment

Rehydration is the cornerstone of cholera treatment. Oral rehydration solution (ORS) is standard, with IV fluid for severe disease. Antibiotics can shorten the course of illness and are reserved for severe illness or high-risk patients. In recent US isolates (2017–2019), the majority were ciprofloxacin-resistant but susceptible to azithromycin and tetracycline. Zinc supplementation is beneficial in children to reduce severity of illness and duration.

Prevention

Food and Water Safety

Strict hygiene practices and food/water precautions should be used by the traveler. Routine antibiotic prophylaxis is not recommended.

Vaccination

The oral cholera vaccine CVD 103-HgR (Vaxchora) is licensed by the FDA for individuals 2–64 years of age traveling to destinations with active cholera transmission (regions with recent or ongoing outbreaks caused by toxigenic O1 strains). Routine use in most US travelers is not recommended.

Vaccine Use

Administration: Single oral dose ≥10 days before potential exposure. Children aged 2–5 years receive half-volume dose (50 mL).

Efficacy: In adults, 90% at 10 days and 80% at 3 months. Over 97% of children aged 2–17 years developed immune response within 11 days.

Restrictions: Not indicated for individuals <2 or >64 years, pregnant, lactating, or immunocompromised individuals.

Side Effects: Mild symptoms like nausea, headache, or tiredness were common. Serious adverse events were rare.

Precautions

Vaxchora should not be given to individuals with known allergies to its components or those who have taken antibiotics in the prior 14 days. Chloroquine may reduce vaccine effectiveness and should be started ≥10 days post-vaccination. The vaccine strain may be shed in stool for a week, so caution is advised around immunocompromised individuals. Medical attention is advised where symptoms manifest and persist.

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