Medires Publishers - Article

Abstract

Cholera is one of the health problems causing significant mortality and morbidity. Little information is available regarding the latest cholera outbreak in Sudan's River Nile State. Here, we detail a cholera case in Sudan's River Nile State. Shendi City's 7-year-old girl arrived with symptoms of fever, chills, diarrhea, vomiting, cramping in her legs, restlessness, and irritability. Laboratory tests revealed cholera infection, which is terribly underreported, badly underdiagnosed, and underestimated. It is presumably uncommon in locations highly syndemic with several diseases. The patient received cholera-supportive treatment, which typically involves rehydration therapy, antibiotics, and electrolyte replacement and is crucial for managing the severe dehydration and electrolyte imbalance that cholera can cause. Following this treatment, the patient is now fully recovered. In this instance, it was critical to track the patient's progress and the treatment results using laboratory data and clinical indicators to adjust the course of treatment as needed based on the reaction. Over 8 million people in Sudan lack access to essential supplies, sanitary conditions, and healthcare due to years of conflict and civil war that significantly destroyed the country's already precarious infrastructure for water, sanitation, and hygiene (WaSH) and healthcare. It is made even worse by a severe lack of necessities, persistent hunger, and bad weather.  Community isolation facilities should have enough sanitation, dependable disposal systems, and a clean water supply to treat and isolate sick patients. It is vital to make sure immunization programs continue. It's also essential to run public health initiatives to educate the local population about nutrition and hygiene.

Key Clinical Message

Over 350 cases of cholera have been identified in Sudan, but the actual number of infected individuals is likely to be far higher. The ongoing humanitarian crisis caused by the nation's civil war has made it challenging to identify and register cases accurately, highlighting the urgent need for improved data collection methods.

Introduction

First identified in 1961, the seventh cholera pandemic still affects people worldwide who do not have enough access to clean water and sanitary facilities. Sub-Saharan Africa reports more than 140,000 probable cases of cholera annually. However, estimates of the global impact are questionable. [1]. Many of these cases happened in underdeveloped areas, such as peri-urban slums, surface-water-dependent rural communities, and regions with complicated circumstances. Eliminating cholera transmission by universal access to water and sanitation is considered improbable, given the current rate of advancement and funding commitments [2]. Cholera is an Acute Watery Diarrhea (AWD) caused by the bacterium Vibrio cholerae serogroups O1 or O139 [3]. It is one of the leading health issues generating significant morbidity and mortality in Asia, Latin America, and Africa [4]. The World Health Organization (WHO) predicts that developing nations will continue to see an increase in cholera cases [5]. There were 172,454 cases of cholera reported in 42 countries in 2015; 41% of these cases were in Africa, 37% in Asia, and 21% in Hispaniola. Of these, 1304 deaths were reported [6]. South Sudan recorded 1818 cases in that year, with 47 deaths (case fatality rate [C.F.R.], 2.6%) [7]. Many low-income nations have an endemic population of V. cholerae, especially in places with poor sanitation and food hygiene standards. The only known natural hosts of V. cholera are humans [6]. The El Tor biotype is the cause of the seventh and ongoing cholera pandemic, which started in Indonesia in 1961. Worldwide, the classical biotype has disappeared, except in Bangladesh, where it reemerged in 2008 at an epidemic level [7]. With the first report of a new outbreak of severe cholera-like disease, V. cholerae 0139, that arose in the Bay of Bengal in 1992 in Bangladesh, the straightforward differentiation between V. cholerae O1 and V. cholerae non-O1 became obsolete in early 1993 [8]. W.H.O. recorded 8200 cases between April and October 2006, including over 230 cholera-related deaths in northern Sudan. Significant population shifts, such as the rise in the number of IDPs returning from both the North and the South, worsen the situation. In addition, the transitional zones are vulnerable to epidemics, particularly cholera, due to their chronic human resource shortage, weak health system, and limited or nonexistent capacity [9]. As of July 30, 2006, there had been 5369 confirmed cases of cholera in Sudan since the disease's first recorded case on April 21, 2005, with 180 deaths and a 3.4% case fatality rate [10]. Cholera is a threat to Sudan and is expected to resurface due to the low socioeconomic development indices in the nation. States that cannot guarantee access to sanitary facilities and safe drinking water still face challenges [11]. Additionally, additional studies come with charges, which are sometimes unaffordable for underprivileged people. However, it is critical to differentiate between the various illnesses because failure to do so can worsen outcomes by increasing morbidity, mortality, and socioeconomic effects, as well as delay in receiving the proper diagnosis and treatment. In this correspondence, we present a case of cholera in Shendi City, Sudan. Our primary focus will be the clinical and laboratory investigations to comprehend this exceptional case better and emphasize the importance of precise diagnosis and appropriate treatment approaches. As healthcare professionals, researchers, and policymakers, your role in the fight against cholera is crucial. Your expertise and dedication can help improve this disease's diagnosis, treatment, and prevention.

Case History

A 7-year-old girl from Shendi City, River Nile State (Figure 1) presented on September 16, 2024, with a 3-day history of fever, cough, acute watery diarrhea, and vomiting with signs of dehydration. In significant quantities, the watery diarrhea was notable for its absence of blood or mucus and the lack of associated abdominal pain. She had low blood pressure (BP) of 95/56 mmHg and tachycardia. Vibrio cholerae O1 had a positive ICT.

Fig 1: The following hospitals and clinics receive cholera cases in Shendi City, Sudan: Shendi Hospital (Al Hawadeth), Shendi Educational Hospital, and Mac Nemir University Hospital. The River Nile State in Sudan is depicted in the top inset (black shading), and the Shendi City cholera cases are shown in the bottom inset (black shading).

Methods

A stool sample was taken and sent to the lab for analysis. The patient's ICT Vibrio cholerae O1 test result was positive, indicating that cholera had been contracted. The stool sample returned negative for the intestinal parasite Entamoeba histolytica, a significant finding that rules out this potential complication. The Vibrio cholerae O1 test on the ICT showed a positive result, indicating that cholera was now present. Laboratory results also showed relative neutrophilia, anemia, and leukocytosis. The negative result for malaria in the peripheral blood smear is a significant finding that should relieve the patient's condition. Table 1 displays the specifics of the conclusions of the lab investigation.

Table 1: Demonstration of the laboratory investigation results of the patient.

Conclusion And Result

Rehydration therapy was administered to the patient to replenish fluids lost due to vomiting and diarrhea and stabilize his condition. After that, the patient remained well-hydrated, and laboratory and clinical indices improved. The patient's recovery was evident a week after discharge, with no symptoms present and all laboratory results within normal limits. The World Health Organization reported 345 cases between January and July 2024, with over 78 cholera-related deaths in Sudan. Significant population movements, such as the rise in displaced persons outside of Khartoum and other locations due to military conflicts, worsen the situation. The transitional zones face a persistent shortage of human resources, a very precarious health system, and limited or no capacity, which leaves them vulnerable to epidemics, particularly cholera.

Discussion

We describe a severe case of a patient with fever, cough, acute watery diarrhea, vomiting, and dehydration symptoms for three days before the presentation. When diarrhea is excessive, it doesn't contain the blood or mucus that causes pain in the abdomen. She had low blood pressure (BP) of 95/56 mmHg and tachycardia. Laboratory tests verified the cholera infection. Despite being a preventable, treatable, and predictable disease, cholera outbreaks continue to claim numerous lives across the country even today, causing significant distress and disruption to communities. A 52-year-old man from Shendi City had a stool sample that tested positive for V. cholerae O1. Similar events happened in River Nile State, Shendi City, where many cases of acute vomiting, fever, and loose stools were recorded in mid-September 2024. An investigation team was swiftly formed with support from the district health system, and a thorough investigation into the outbreak was carried out with the sole objective of locating more cases and sources of cholera infection and recommending suitable countermeasures. Given Sudan's low socioeconomic development metrics, cholera remains a threat and is probably going to recur. It also presents a challenge to countries where there is uncertainty about access to safe drinking water and basic sanitation [11]. In the current case, leukocytosis, anemia, and relative neutrophilia were found in the laboratory results, and the patient also had symptoms of cholera, including fever, coughing, acute watery diarrhea, vomiting, and signs of dehydration.

In summary, our research validates the hypothesis that cholera epidemics are linked to a collapse of the social infrastructure and inadequate personal hygiene, specifically access to clean water. This study's results validate several established cholera risk factors, including food hygiene and travel history. The main risk factors for the spread of cholera include drinking contaminated water and using inadequate food preservation techniques [12,13]. Because systematic testing for Vibrio cholerae O1 is uncommon, it's possible that the regions with the most significant actual cholera burden won't receive the world's meagre supply of oral cholera vaccines or OCVs [14]. We must emphasize the need for better hygiene practices to prevent and control cholera outbreaks.

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