# Prevalence of Vibrio cholerae in an Acute Watery Diarrhea Outbreak in Sulaymaniyah City, Iraq

## TL;DR

This study analyzed a 2023 cholera outbreak in Sulaymaniyah, Iraq, finding a 0.015% prevalence and identifying antibiotic resistance patterns in Vibrio cholerae isolates.

## Contribution

The study provides molecular and antibiotic resistance data from a recent cholera outbreak in Sulaymaniyah, highlighting the need for updated treatment guidelines.

## Key findings

- The overall infection rate was 28.91% with highest rates in August and among females.
- All isolates showed complete resistance to amikacin, amoxicillin, amoxiclav, nalidixic acid, and trimethoprim.
- Phylogenetic analysis linked the strain to the V. cholerae Kuwait1 strain, suggesting regional spread.

## Abstract

Cholera is a life-threatening diarrheal disease caused by Vibrio cholerae, with recurring outbreaks in Iraq, including the Kurdistan Region. Despite its endemic nature, outbreaks have primarily been reported by the health sector without comprehensive molecular epidemiological investigations. Limited studies have characterized outbreak dynamics, prevalence, and antimicrobial resistance, hindering effective public health interventions. This study aimed to analyze the prevalence, molecular characteristics, and antibiotic resistance of V. cholerae isolates from the 2023 outbreak in Sulaymaniyah, Kurdistan, Iraq. A total of 1200 diarrheic stool samples were collected from Shar Hospital between July and October 2023. Bacterial isolation was performed using microbiological methods and automated VITEK 2 analysis, followed by serological identification (O1 and O139 antisera) and 16S rRNA gene sequencing. Antibiotic susceptibility testing (AST) was conducted to assess resistance patterns. The outbreak prevalence was 0.015%, with the highest infection rate in August (0.009%). The overall infection rate was 28.91% (347/1200), with the most affected age groups being 19–33 years (27.66%) and 34–48 years (26.22%). Infection was more common in females (55.6%) than males (44.4%). Phylogenetic analysis revealed high genetic similarity to the V. cholerae Kuwait1 strain, suggesting potential introduction from southern Iraq, possibly due to an influx of tourists. Furthermore, antibiotic susceptibility testing revealed that all V. cholerae isolates were susceptible to most tested antibiotics; however, complete resistance (100%) was observed against amikacin, amoxicillin, amoxiclav, nalidixic acid, and trimethoprim, with partial resistance (30%) to tetracycline. Cholera remains a major public health concern in Kurdistan, particularly in Sulaymaniyah, due to recurrent outbreaks. Molecular techniques provided crucial insights into outbreak tracking and genetic relatedness, while AST profiling highlighted the urgent need for revised treatment guidelines. Strengthening water sanitation, continuous antimicrobial resistance monitoring, and targeted public health interventions are essential for preventing future outbreaks.