The disease is characterized by acute watery diarrhoea, often leading to severe dehydration and death if left untreated. Cholera outbreaks are often triggered by poor sanitation, lack of clean water, and overcrowded conditions. This article will review the history of cholera outbreaks, recent global epidemics, and provide a detailed overview of the recent cholera outbreak in Sudan.

Cholera, caused by the bacterium *Vibrio cholerae*, remains a significant public health issue globally, particularly in low-resource settings. The disease is characterized by acute watery diarrhoea, often leading to severe dehydration and death if left untreated. Cholera outbreaks are often triggered by poor sanitation, lack of clean water, and overcrowded conditions. This article will review the history of cholera outbreaks, recent global epidemics, and provide a detailed overview of the recent cholera outbreak in Sudan.

Cholera is primarily caused by *Vibrio cholerae*, a Gram-negative bacillus. The bacteria produce a toxin known as cholera toxin (CT), which binds to receptors in the small intestine, leading to increased cAMP levels and massive efflux of water and electrolytes into the intestinal lumen. This results in profuse watery diarrhoea commonly described as "rice water" stools.

Transmission

The disease is primarily transmitted through contaminated water or food, and it is often associated with poor sanitation and hygiene practices. Human-to-human transmission is rare, and the incubation period ranges from a few hours to 5 days.

Global Cholera Outbreaks

Historical Overview

Cholera has caused seven major pandemics since the early 19th century. The first pandemic began in 1817 in the Indian subcontinent and spread across Asia, the Middle East, Europe, and Africa. The seventh pandemic, which started in 1961, was caused by the *El Tor* biotype of *V. cholerae* and continues to affect many regions globally.

• Yemen (2016–2022),Yemen experienced one of the largest modern-day cholera outbreaks. Civil war, collapse of healthcare infrastructure, and widespread famine contributed to the epidemic. Between 2016 and 2022, over 2.5 million cases were reported, with more than 4,000 deaths. 
• Haiti (2010–2019), In 2010, a severe outbreak occurred following the devastating earthquake. This outbreak was later traced to a United Nations peacekeeping camp. Over 820,000 cases and 10,000 deaths were reported by 2019. The disaster highlighted the importance of rapid response and coordinated public health strategies in preventing large-scale outbreaks.
• Democratic Republic of the Congo (DRC, 2020) The DRC remains vulnerable to cholera due to ongoing conflict, internal displacement, and poor access to clean water. In 2020 alone, the DRC reported over 25,000 cholera cases, with nearly 500 deaths.

• Lack of Clean Water: Contaminated water is the primary source of cholera outbreaks. Urban slums, refugee camps, and conflict zones are particularly at risk.
• Poor Sanitation: Overcrowding and inadequate waste disposal exacerbate the risk of outbreaks.
• Natural Disasters: Floods and earthquakes can disrupt clean water supply systems and lead to cholera outbreaks.
• Conflict Wars and civil unrest damage infrastructure, making it harder to access safe water and health services.

 Background

Sudan has a history of cholera outbreaks, most notably in 2017 and 2019. In 2023, a new cholera outbreak occurred, largely exacerbated by ongoing political unrest, displacement, and deteriorating healthcare systems.

Epidemiology

The most recent cholera outbreak in Sudan began in mid-2023 and affected several regions, including Khartoum, Gezira, White Nile State and parts of Darfur. Thousands of cases were reported, and the lack of clean water, coupled with overcrowded conditions in internally displaced persons (IDP) camps, contributed to the rapid spread of the disease. As of late 2023, the World Health Organization (WHO) reported over 10,000 cases, with a mortality rate of around 2%.

 Contributing Factors

• Political Instability: The ongoing political crisis in Sudan has led to the collapse of many public health systems, making it difficult to implement cholera control measures.
• Refugee and IDP Camps: Many people displaced by the conflict live in overcrowded conditions without access to clean water or sanitation.
• Rainy Season: The outbreak coincided with the rainy season, which exacerbated the spread of cholera through contaminated water sources.
• Healthcare Infrastructure: The shortage of healthcare workers, medicine, and functional healthcare facilities further complicated the response to the outbreak.

Response

• The Sudanese Ministry of Health, supported by international organizations like WHO and Médecins Sans Frontières (MSF), launched a comprehensive response, including:
• Cholera Vaccination Campaigns: Oral cholera vaccines (OCV) were deployed in high-risk areas.
• Water, Sanitation, and Hygiene (WASH) Interventions: Efforts were made to provide clean water and improve sanitation in affected areas.
• Case Management: Cholera treatment centres (CTCs) were set up to manage severe cases and provide rehydration therapy.
• Despite these efforts, the ongoing conflict has made it difficult to fully control the epidemic, and sporadic cases continue to emerge.

Clinical Presentation

Typical cholera patients present with:

• Acute onset of watery diarrhoea, often described as "rice-water" stools
• Vomiting
• Severe dehydration, which can lead to hypovolemic shock and death if untreated

 Diagnosis

• Clinical Diagnosis: Suspected in any patient with acute watery diarrhoea, particularly in areas with known outbreaks.
• Laboratory Diagnosis: Confirmation is done by stool culture, polymerase chain reaction (PCR), or rapid diagnostic tests (RDTs).

 Treatment

• Rehydration Therapy: The cornerstone of cholera treatment. Oral rehydration salts (ORS) are used for mild to moderate cases, while intravenous fluids (Ringer’s lactate) are necessary for severe dehydration.
• Antibiotics: Used in severe cases to shorten the duration of diarrhea and reduce bacterial shedding. Commonly used antibiotics include doxycycline, azithromycin, or ciprofloxacin.
• Zinc Supplementation**: Especially recommended for children to reduce the duration and severity of diarrhoea.

 Prevention and Control

• Vaccination: Oral cholera vaccines, such as Shanchol and Euvichol, are effective in preventing outbreaks and are recommended in high-risk areas.
• Improved WASH (Water, Sanitation and hygiene): Access to clean water, proper sanitation, and hygiene education are critical in preventing cholera.
• Public Health Surveillance: Early detection and rapid response are key to containing cholera outbreaks.

Siferaia rural hospital in White Nile State, from December 8 to December 26, 2023. Data were collected from medical records, including demographics, clinical symptoms, and outcomes. Stool samples were tested for V. cholerae using rapid diagnostic tests and culture. Data analysis was performed using SPSS version 22.

Results: A total of 205 cholera cases were recorded, with a higher prevalence among females (57.5%). The most affected age group was 10-20 years (22.3%). The majority of cases (86.8%) were from Al-Siferaia village, linked to contaminated irrigation canal water. Dehydration levels varied, with 38.6% experiencing mild, 3% moderate, and 22.8% severe dehydration. Treatment primarily involved Oral Rehydration Solution (68.7%), with a case fatality rate of 6.3%.

Conclusion: The outbreak in Al-Siferaia was primarily due to contaminated irrigation water. The high attack and case fatality rates highlight the need for improved water quality, sanitation, and healthcare infrastructure. Immediate measures, including comprehensive WASH programs (Water, Sanitation and hygiene for all initiative), enhanced public health surveillance, community education, vaccination, and strengthened healthcare facilities, are essential to prevent future outbreaks. It is important to implement comprehensive WASH programs, strengthen public health surveillance, enhance community education, introduce vaccination programs, improve healthcare infrastructure, and conduct further research to mitigate cholera risk factors.

A 35-year-old male from Gezira, Sudan, presented to a local clinic with a 2-day history of profuse watery diarrhoea, vomiting, and muscle cramps. He had no prior history of significant medical issues but had recently moved to an IDP camp after fleeing violence in his village. On examination, he was lethargic, with dry mucous membranes, sunken eyes, and decreased skin turgor. Vital signs revealed tachycardia (120 bpm), hypotension (BP: 80/50 mmHg), and a normal respiratory rate.

The clinical presentation was highly suggestive of cholera. Rapid rehydration with intravenous Ringer’s lactate was initiated, and stool culture confirmed *V. cholerae* infection. The patient responded well to rehydration therapy and was discharged after 48 hours of observation with instructions on using ORS at home.

Cholera continues to pose a significant global health threat, particularly in regions with inadequate water and sanitation infrastructure. The recent outbreak in Sudan highlights the vulnerability of conflict-affected regions to cholera epidemics. Rapid response, public health interventions, and improved access to clean water and healthcare services are essential to control future outbreaks. Continued global cooperation is necessary to prevent and manage cholera outbreaks effectively.