The first recorded cholera epidemic in Korea, which occurred in 1821, was introduced from trade with China [1]. There were more than 10 subsequent epidemics between 1821 and 1910, when Japanese colonial rule began [2]. As the country opened to the rest of the world, the concept of cholera, which used to be regarded as an infectious folk illness, has become more scientific. From the opening of the country in 1876 to the start of colonization in 1910, infection control programs were implemented as directed by the Japanese government [3].

There were several subsequent cholera outbreaks during the period of Japanese colonial rule. The incidence of cholera peaked in 1919 and 1920 in the aftermath of the Independence Movement Day (March 1st) [4]. During the period of Japanese colonial rule, the incidence of cholera and cholera-related deaths decreased as a result of quarantine procedures [5]. However, given that the incidence of other infectious diseases did not decline or increased, public health projects under Japanese colonial rule were largely ineffective [6].

Two million out of 5 million Koreans living overseas returned to the country after it was liberated from Japan. As many people migrated to large cities, hygiene deteriorated greatly. The USAMGIK restructured the Korean Governor-General's administration and established the Ministry of Health and Welfare. After the discontinuation of the Japanese health administration system, the Ministry of Health and Welfare established by the USAMGIK did not function very well due to a lack of human resources. Various infectious diseases epidemics broke out under the circumstances of the unclear roles of the police in containing infectious diseases outbreaks [7].

In May 1946, cholera was introduced to the country by a ship returning from Guangdong, China. An epidemic started in Busan, then soon spread nationwide. There were 15,644 cases of cholera, and 10,181 cholera-related deaths [8]. People with cholera experienced severe dehydration as a result of profuse vomiting and diarrhea, and it was difficult to obtain sufficient fluids, which were essential for treatment.

The following passage describes the situation at that time [9]:

In the 1960s, El Tor cholera replaced classical cholera. El Tor became established during the 7th pandemic of cholera, which began in Sulawesi, Indonesia. El Tor cholera [10] is characterized by lower volumes of and less frequent diarrhea, a lower case fatality rate, and a higher percentage of people who carry cholera without symptoms.

There were 11 cholera epidemics in Korea between 1963 and 2001 [11]. They generally occurred in summer and fall from August to October, and they may have been associated with environmental factors such as seawater temperature. The duration of the epidemics ranged from 11 days in 1999 to 77 days in in 1970 [12]. Most of the epidemics began in coastal areas or ports such as Incheon, Busan, Gunsan, Masan, and Sinan (Table 2) [11].

When the last classical cholera epidemic occurred in 1946, there were 15,644 cases, and 10,181 deaths with a case fatality rate of 65%.

Hee-Myoung Park, who has served as President of Kyungpook National University Hospital and Dean of the College of Medicine, Kyungpook National University, was dispatched to Daegu Burip Hwaeseng Hospital (currently, Daegu Medical Center) to treat patients during the cholera epidemic. He described those days as follows [20]:

I realized that cholera patients could lose 15 to 20 kg due to dehydration in just 3 or 4 days. Their excreta looked like rice water, and although the excreta did not have much odor, they had sufficient volume to flood the floor of the hospital room and corridor. We had to wear rainboots. The patients were all skin and bones due to severe dehydration, and they looked like old men and women as they had wrinkles all over their bodies. We relied on fluids, which were rarely provided by the army.

Professor Yong-Suk Ki at Gyungsung college of medicine, the only surviving person with first-hand experience in cholera prevention during the 1946 outbreak, trained faculty members, staffs, and students of the college of medicine at the request of the USAMGIK, organized cholera prevention teams, and sent them to key areas [25]. Cholera prevention teams from Gyungsung college of medicine submitted the Incheon Marine Quarantine Project Report, which is regarded as the first academic article on cholera epidemics in Korea after liberation.

Here is an account of Professor Jong-Hui Jeon, who experienced several cholera outbreaks, remembered the experience [26]:

I experienced two classical cholera outbreaks and seven El Tor cholera outbreaks. After cholera treatment was shifted to rehydration, people recognized that cholera was no longer a terrifying disease, and that it was is important to provide water as soon as possible to treat the disease. As a result, we were able to reduce the case fatality rate of the 1963 epidemic to 5.1%. When a cholera epidemic occurs, we should abstain from the idea of identifying cholera carriers as we did in the past, and quarantine patients in diarrhea centers for treatment. Then, you will reach a simple conclusion that ordinary hygiene measures, including a general hygiene knowledge and the use of disinfectants, would be sufficient to stop the spread of cholera.

In 2001, the Central Epidemiological Investigation Team and the Epidemiological Investigation Team of North Gyeongsang Province established the prevention task force within public health centers in Yeongcheon and Gyeongju; strengthened monitoring of patients with diarrhea; and visited households in person, conducting a questionnaire survey and collecting stool samples to identify individuals who had eaten food at a restaurant for taxi drivers. To stop further spread from the restaurant, a microbiological screening was conducted of employees who worked with food in the risk areas (the areas with confirmed cases where there was a risk of further spread). To supplement the questionnaire survey, members of the investigation team reviewed medical records and interviewed healthcare professionals. To identify the source of infection, the Local Quarantine Center and the Department of Intestinal Pathogens at the Korea National Institute of Health conducted microbiological screening and a polymerase chain reaction (PCR) test of samples of marine organisms, seawater, and plankton in order to identify possible reservoirs of infection [19].

As cholera is mediated by water and food and multiple individuals can become infected from a single source, it is imperative to seek a prevention response immediately after an outbreak is identified. All cases should be reported without delay when an infected patient, physician, or anyone carrying cholera is diagnosed, an infected individual's dead body is examined, or when a case fatality occurs. The case should be reported by fax to the head of the responsible health center or through the Integrated Disease and Health Control System (http://is.cdc.go.kr).

Since 2002, WHO has selected the pathogens that are expected to increase in as a result of climate change, and have evaluated correlations between these pathogens and the environment. The WHO selected 11 pathogens, which require an early warning system to prevent their outbreak and spread, and cholera was the only intestinal pathogen included. Since 2005, Korea has operated Vibrio Net, a project investigating pathogenic Vibrio in the marine environment, and has performed monitoring on coastal seawater in Korea [27].

In the event of a cholera outbreak, a prevention task force has been established within the government to perform cholera prevention activities with the assistance of expert consultants. In cooperation with professional organizations such as the Korean Society of Infectious Diseases, the Korean Medical Association, and the Korean Hospital Association, cholera information and precautions are informed across the country.