Outbreak investigation of cholera in Birgunj, Nepal: An unmatched case-control study

Outbreak investigation of cholera in Birgunj, Nepal: An unmatched case-control study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outbreak investigation of cholera in Birgunj, Nepal: An unmatched case-control study Devichandra Thapa, Jyoti Kuikel, Prabesh Paudel, Rebisha Sapkota, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8386341/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cholera remains a persistent global health threat. Although it is preventable and treatable, it has disproportionality affected vulnerable population lacking water and sanitation particularly among the low-middle income countries. The recent cholera outbreak was seen in Birgunj metropolitan city, Madhesh province, eastern part of Nepal in August 2025. Out of one thousand one hundred fourteen, hundreds of hospitalized within days, exposed critical gaps in water safety, sanitation and community awareness. The study aims to investigate cholera outbreak. Methods The population-based unmatched case-control study with 1:1 ratio, 63 confirmed cholera cases and 63 community controls from the most affected wards of Birgunj were enrolled in the study. Data was collected though face-to-face interviews using a structured questionnaire on WHO guidelines, alongside secondary outbreak records. Statistical analysis with SPSS included descriptive measures, chi-square tests and binary logistic regression to identify significant risk factors for cholera. Results The study revealed that limited awareness about cholera complications (OR: 2.30, 95% CI: 0.64–8.28) and preventive measures (OR: 2.87, 95% CI: 1.23–6.73) significantly increased the risk of cholera among the participants. The cholera risk was strongly shaped by socio-demographic and behavioral factors. The participants aged 5–49 years (OR: 2.81, 95% CI: 1.45–6.92), individuals from Muslim ethnic groups (OR: 12.26, 95% CI: 4.98–30.14), and those without formal education (OR: 8.85, 95% CI: 2.57–30.46) were disproportionately affected. Household and community practices such as consuming street food (OR: 11.47, 95% CI: 4.86–27.07), relying on untreated public tap water (OR: 19.77, 95% CI: 4.40-88.76), unsafe stool disposal (OR: 17.95, 95% CI: 4.64–66.61), cross-connections (OR: 2.461, 95% CI: 1.49–4.04) significantly increased risk of cholera. The effective preventive measures improving sanitation and hygiene practices, strengthening community awareness through education and behavioral change and long-term measures like oral cholera vaccination, regular water chlorination and active surveillance. Conclusion Cholera in Birgunj was influenced by social, behavioral and environmental factors, indicating the urgent need for stronger community awareness and behavioral change, safe water and sanitation practices. Cholera Acute watery diarrhea Outbreak Investigation Unmatched Case-Control Study Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. INTRODUCTION Cholera still poses a serious public health threat globally ( 1 ). U.S. Centers for Disease Prevention and Control (CDC) claimed that cholera is responsible to kill tens of thousands of people around the world every year ( 2 ). According to WHO, 804,721 cholera cases and 5,805 deaths were reported across 33 counties of five WHO regions in 2024. By the end of first quartile 2025, 25 countries had reported cholera or acute watery diarrhea with 116,574 cases and 1,514 deaths mostly from Africa, Eastern Mediterranean and Sout-East Asia ( 3 ). Based on the information of European Centers for Disease Prevention and Control, since March 17, 2025 about 16,111 new cholera cases with 372 new deaths have been reported worldwide and these new cases were from Asian and African countries including Afghanistan, Bangladesh, India, Nepal and others ( 4 ). Cholera is an extremely virulent disease of inequality that cases severity among poor and the most vulnerable people. Approximately 3–5 million people worldwide suffer from cholera with more than 100,000 deaths. Particularly, it spreads in places where living conditions are difficult with lack of safe drinking water and improper sanitation ( 5 ). Around 60 percent of population are at risk of diarrheal disease outbreak due to persistent socio-economic issues like poverty, poor sanitation and weak infrastructure in Nepal ( 6 ). The study conducted by have shown that the most known risk factors for cholera outbreak are contaminated water sources, unwashed raw vegetables, lack of adequate latrines and heavy rainfall and floods ( 7 ). It is necessary to identify the sources and associated risk factors of cholera outbreak in developing countries like Nepal. On 22nd August 2025, the Epidemiological Disease Control Department (EDCD) notified the sudden rise of acute watery diarrhea from health facilities in multiple wards including 3, 11, 12, 13, 14 and 16 of Birgunj metropolitan city, confirming cholera outbreak. Several activities were conducted in the outbreak areas including over 300 patients were treated across different hospitals, free treatment were provided through public and private hospitals ( 8 ). Rapid diagnostic tests and lab confirmation were done along with water samples testing by World Health Organization(WHO) ( 9 ). The recent data showed that out of 540 cases, 257 cases were recovered, and 283 cases were active cases ( 10 ). Different public health measures like awareness campaigns on hygiene and safe water practices, distribution of ORS packets and door-to-door outreach for hygiene promotion were conducted by different organizations ( 11 ). Although cholera is predictable, preventable and treatable, it continues to spread widely across the different areas of the nation ( 12 ). The recent outbreak of Birgunj has been marked as one of Nepal’s most significant public health emergencies since Jajarkot epidemic of 2009 ( 8 ). The outbreak is so rapid that it has affected over 300 individuals being hospitalized within days with multiple requirements of intensive care. On the other hand, despite Nepal’s declaration of being open-defecation-free in 2019, the outbreak highlighted that it is a critical failure in water safety and sanitation infrastructure. One of thearticles revealed that those patients admitted to hospitals had low awareness and delayed care-seeking behavior, causing a great barriers to early treatment ( 13 ). Most of the cholera outbreak investigation in Nepal have focused on patients who reach health facilities, with much of the research concentrated in Kathmandu valley. This pattern likely reflects weak surveillance system and limited diagnostic capacity in rural areas. In contrast, during 2025 outbreak in Birgunj, multiple external development partners and local government worked together to combat the outbreak ( 14 ). Therefore, to visualize and understand the real scenario of the cholera outbreak the study was conducted to identify the risk factors of cholera outbreak and explore preventive and control measures in later years. 2. METHODS 2.1 Study design The population-based unmatched case control study with a 1:1 case-control ratio to identify the risk factors for cholera transmission was used. The one control over a case was used due to resource constraints. According to EDCD, multiple wards; 11, 12 and 13 of Birgunj metropolitan city were highly affected by cholera outbreak. 2.2 Case and control identification and recruitment process Based on the nature of the outbreak, confirmed cases were those people or patient aged five years and above with laboratory diagnosed with V. cholerae from specimen culture from August 22, 2025. The population control was those people living in the same community who had no history of diarrhea since last five days before August 22, 2025. The control can be either the people of the same household or neighbors of confirmed cases. The information on the confirmed cases was obtained from the Public Health Office, Birgunj, hospitals and health office. All the confirmed cases were tracked. The information on confirmed cases’ names (only for purpose of tracking the case and later it was coded for confidentiality), address, contact details along with the FCHVs of those confirmed communities/wards were also listed accordingly. The controls were selected based on the household or neighbor of case, all the eligible members were listed and those who were able to answer questions of questionnaire and those who were willing to participate were selected. The number of controls from each case household was one based on the case-control ratio distribution. 2.3 Sample size calculation At first, being the study case control, the sample size determination was initially formulated from the formula; n=(zα/2 + zβ) 2 p(1-p) (r + 1)/d 2 r where, zα/2 is assumed 1.96 at 95% CI, zβ is assumed 0.84 at 80% power, p is 0.03 attack rate, r is 1 and d is calculated to be 0.17 (from the formula; d = p-p 1 where p 1 is formulated from the formula, p 1= p (OR)/1 + p (OR-1) where the odds ratio was 2.0. These parameters (including odds ratio, attack rate, p value) were taken from the study conducted by Subedee et al (2025). We calculated sample size to be 126 where 63 cases and 63 controls were taken. Regarding the selection of wards, after visiting the field and reviewing reports, the wards with high number of cases were identified in wards 11, 12 and 13. That is why, the sample units were taken from these wards. 2.4 Research tools and techniques The face-to-face interview was conducted among the cases and controls enrolled in the study based on the structured questionnaire. The questionnaire was prepared referring to the WHO guidelines on cholera outbreak investigation and later translated into Nepali language. The time required to interview cases and controls was approximately 15–30 minutes. For identifying the status of cholera outbreak, data from the sub-metropolitan health office, Birgunj was taken. To explore the preventive and control measures, various literatures from the published similar study design articles were collected and among all the suitable and effective measures were enlisted in the study. 2.5 Data analysis procedure The primary data were collected from the interview with confirmed cases and controls of wards 11, 12 and 13 whereas, the secondary data including the number of new confirmed cases and suspected cases based on wards, hospital admission, treatment from Birgunj metropolitan health office were collected from August 20, 2025, to September 14, 2025. With the help of MS-Excel and IBM SPSS version 21, the data was managed and analyzed. MS-Excel was used for data coding and data entry. Later the exported data were analyzed in SPSS. The descriptive statistics like frequency distribution, designing epidemic curve and determining attack rate, case fatality rate were computed and visualized in graphs. All the categorical explanatory variables were cross tabulated with the dependent variable and described in terms of frequency and proportion, for case and control groups. To identify whether the independent variables are statistically significant with dependent variable, chi-square test was computed at p value < 0.05 and binary logistic regression was assessed to find out the crude odds ratio with 95% confidence intervals. A p-value < 0.05 was considered statistical significance. 2.6 Study variables From the rigorous literature review, the explanatory/exposure variables included in the study were demographic and socio-economic factors (age, gender, ethnicity, main source of income, educational qualification, family type), WASH associated factors (street food consumption and hygiene maintenance, raw food consumption, main source of drinking water, experience of water shortage, drinking water treatment methods, availability of latrine/toilets and its type, child stool disposal practice, handwash practice and presence of cross connection) and knowledge related factors (about cholera, its causes, main symptoms, mode of transmission, complications, preventive measures and first control action to be taken). The figure above (Fig. 1 ) shows the core structure of case-control study on cholera, comparing individuals with confirmed cholera (Cases) to those without the disease (controls). Both groups are assessed for exposure to potential risk factors such as unsafe water or poor sanitation and then categorized as exposed and non-exposed. This design helps to identify which exposures are more common among cases, guiding targeted public health interventions. Operational definition Case Those people or patient aged five years and above with laboratory diagnosed with V. cholerae from specimen culture from August 22, 2025. Control Those people living in the same community had no history of diarrhea since last five days before August 22, 2025. The control can be either the people of the same household or neighbors of confirmed cases. Ward definition The grassroot level, representing administrative units of local government under municipality and rural municipalities. In the study area, there were 32 wards in Birgunj metropolitan city, from where the study selected three wards i.e. ward 11, 12 and 13 having highest cases of cholera. Educational qualification The educational qualification was broadly categorized into illiterate, who were unable to read and write and also included those participants who had received informal education and are able to write their names, primary level indicating those people who had completed their formal education till grade 5, secondary level included participants completing their formal education till grade 10, diploma/bachelor included 11, 12 or 3 years course completion after grade 10 and higher studies. . Hygiene maintenance on street food consumption The good hygiene of street foods was assessed based on the clean-washed utensils used, a stall inside a concrete house, a food seller using gloves and serving in paper or plastic disposal utensils. In contrast to it, poor hygiene included presence of pests and flies around the foods, uncovered foods, stall at open space, open ground, or near school gates, food seller not using gloves, serving food in the same utensils by simply washing it with water and uncovered water storage to wash utensil. Handwashing practice The participants who practice regular handwashing with clean running water and proper soap at all critical times as recommended by WHO i.e. after using toilet, before preparing or cooking food, before eating or feeding others, after contact with any contamination source (handling water, cleaning, touching animals, coughing/sneezing) whereas, not regularly is considered as not washing hands consistently or only occasionally (not practicing handwash after toilet or before food preparation), only with water (skipping handwash with soap). Presence of cross connection The unsafe link between drinking water system and contaminated sources including sewage or drainage lines in home and public taps. 3 RESULTS During the field visit to Birgunj, secondary data from the sub-metropolitan health office was collected to determine the number of reported cholera cases. In addition, community-based data was collected. Therefore, this section is broadly categorized into results derived from health care facilities and findings from the empirical study. 3.1 Health facility case review 3.1.1 Epidemic Curve of cholera outbreak As shown in the epidemic curve (Fig. 2), the number of new cases of cholera changed every day in Birgunj over 26-day period. For the first 10 days, the situation was normal with cases mostly between 1 and 11. However, on August 22, there was a sharp increase, including 43 cases. In August 23, cases reached 82, a dramatic spike. The peak was on August 27, 2025, with 106 cases which is the highest cases in the entire period. After the intervention and control measures were applied due to which the cases began to drop from 84 on August 28 to 36 on September 6, 2025. 3.1.2 Attack rate of cholera The total number of new cases during the outbreak (from August 22, 2025, till September 7, 2025) was 989 and the population at risk during the outbreak (Population of Birgunj sub-metropolitan city during the outbreak according to sub-metropolitan health office) was 133238 so the attack rate was 0.74%. 3.1.3 Case fatality rate The number of deaths due to cholera during the outbreak was 0 and the number of confirmed cases from August 22, 2025, to September 7, 2025, was 1114 so the case fatality rate was 0 per 100 population. 3.1.4 Age-Sex wise number of acute gastroenteritis/ possible cholera cases The figure (Fig. 3) shows the number of female and male across different age groups in a population with acute gastroenteritis or possible cholera cases in Birgunj during cholera outbreak. It shows that there was early exposure of disease among the children aged 0–4 years i.e. 19 among female and 15 among male. The most affected age group were 15–24 years, similarly age group 25–54 years were affected. There was decline among the old adults aged 55 and above. 3.1.5 Ward wise distribution of cholera The figure (Fig. 4) shows the ward-wise distribution of 693 cholera cases in Birgunj sub-metropolitan city up to August 29, 2025. Ward 12 is the epicenter, with a dramatic increase of 135 cases, indicating a major outbreak cluster followed by ward 13 with 98 cases and ward 11 with 65 cases indicating high transmission in these clusters. Wards 1–10 and 16–32 show low case counts, mostly below 20, with many wards reporting fewer than 5 cases. The curve shows a sharp rise from ward 10 to ward 12, followed by gradual decline, resembling a localized outbreak curve. 3.1.6 Number of hospitalized cholera cases, Birjung The figure above (Fig. 5) shows the number of cholera admissions per day among 195 cases, excluding wards 11–14. These wards were excluded because there were no hospitalized cholera cases from these wards. Although wards 11–14 were excluded, the figure shoed a secondary rapid increase in other wards. Due to increased community awareness and reporting, expansion of surveillance and testing, the admission pattern reached its peak on August 26 with 38 cases admitted to hospitals. From August 27, admissions declined steadily. 3.1.7 Number of cases in ICU, HDU and general wards, Birjung The figure above (Fig. 6) shows the number of cholera cases admitted to ICU, HDU and general wards in Birgunj hospital from August 24 to August 29, 2025. Most cholera patients were admitted to the general ward, peaking at 232 cases on August 27. This reflects most of the cases were managed with ORS, IV fluids and basic monitoring. ICU cases increased from 22 to 35, indicating a growing number of severe cases requiring intensive care. HDU cases remained low (1–6 per day), suggesting limited use or capacity. 3.2 Information from the case-control study 3.2.1 Socio-demographic characteristics The table below (Table 1) shows the comparison of 63 cases and 63 controls across various demographic and socio-economic characteristics. The Chi-square test is used to assess whether differences between groups are statistically significant. A p-value < 0.05 indicates a meaningful association. As shown in the figure, majority of cases were from the age group 5–49 years. Among them 49.5% were cases and remaining were control. The data showed that there was statistically significant association with age. Cholera cases were less common among older adults. The cholera case was common among female participants than male. There was no statistically significant difference though slightly more females were affected. Talking about the ethnicity, in the study area comprised exclusively Hindu and Muslim communities, with no representation from other religious groups. There was highly statistically significant difference between the ethnicity where Muslims were disproportionately affected compared to Hindus. The main source of income among the participants was business, alongside those participants with source of income as service were higher among the controls with 66.7%. There was no significant difference across the main source of income. There was strong association between education and cholera cases where illiteracy was more common among cases. Similarly, the family type did not show the significant association between cholera. Table 1 Frequency distribution and analysis of socio-demographic characteristics of the participants Characteristics Case n (%) Control n (%) Chi-square value df p value Age (Years) 5–49 47 (49.5) 48 (50.5) 5.323 1 0.021 50 and above 8 (25.8) 23 (74.2) Gender Male 25 (36.8) 43 (63.2) 2.84 1 0.091 Female 30 (51.7) 28 (48.3) Ethnicity Hindu 8 (14.3) 48 (85.7) 35.33 1 < 0.001 Muslim 47 (67.1) 23 (32.9) Main source of income Agriculture/Daily wage labor 16 (50.0) 16 (50.0) 4.361 3 0.225 Business 20 (37.7) 33 (62.3) Service (private/government) 7 (33.3) 14 (66.7) Food vendor/Street food seller 12 (60.0) 8 (40.0) Education Illiterate 21 (56.8) 16 (43.2) 22.982 3 < 0.001 Primary level ( 1 – 5 ) 21 (67.7) 10 (32.3) Secondary level ( 6 – 10 ) 9 (33.3) 18 (66.7) Diploma and higher 4 (12.9) 27 (87.1) Family type Nuclear 9 (31.0) 20 (69.0) 2.438 1 0.118 Joint/Extended 46 (47.4) 51 (52.6) Note: Figures in parenthesis indicate the percentage of representative frequencies 3.2.2 Factors associated with Water, Sanitation and Hygiene (WASH) The table (Table 2 ) shows the patterns and significant associated factors of cholera by comparing cases (n = 63) and control (n = 63). As shown in the table, street food consumption was strongly associated with cholera (p < .001). A higher proportion of cases (69.2%) consumed street food compared to controls (30.8%) t. Similarly, raw food consumption like meat and vegetables also showed a significant association (p < .001). Cases (65.6%) were more likely to consume raw food compared to control (34.4%). However, hygiene maintenance of street food did not show statistical significance though poor hygiene was more common among cases. The main source of drinking water was significantly associated with cholera (p < 0.01). cases were more likely to rely on public taps (57.7%) compared to controls, while control more often used handpumps or deep boring (93.5%). Only 29.6% of cases treated their water compared to 70.4% of controls (p = 0.006). The type of latrine showed a significant association (p = 0.0014). All individuals practicing open defecation were cases, while unimproved pit latrines were only reported among controls. Improved pit latrines were more common in both groups. Handwashing practice was significantly associated with cholera (p = 0.022). Not washing hands regularly was more common among cases (58.5%) compared to controls (41.5%). The presence of cross connection in water supply showed a very strong association (p < 0.001). All controls reported no cross-connection, while 66.3% of cases had cross-connections in their water supply. Table 2 Frequency distribution and factors associated with cholera with water, sanitation and hygiene Characteristics Case n (%) Control n (%) Chi-square value df p value Street food consumption Yes 45 (69.2) 20 (30.8) 35.71 1 < 0.001 No 10 (16.4) 51 (83.6) Hygiene maintenance of street food Poor hygiene 49 (48.0) 53 (52.0) 4.87 2 0.088 Good hygiene 4 (33.3) 8 (66.7) Don’t eat outside 2 (16.7) 10 (83.3) Raw vegetables and meat consumption Yes 42 (65.6) 22 (34.4) 25.53 1 < 0.001 No 13 (21.0) 49 (79.0) Main source of drinking water Pipe water into dwelling/yard 8 (47.1) 9 (52.9) 23.77 2 < 0.001 Public tap 45 (57.7) 33 (42.3) Handpump or deep boring 2 (6.5) 29 (93.5) Experience of water shortage Yes 34 (43.0) 45 (57.0) 0.03 1 0.857 No 21 (44.7) 26 (55.3) Drinking water treatment Yes 16 (29.6) 38 (70.4) 7.55 1 0.006 No 39 (54.2) 33 (45.8) Latrine availability Yes 53 (53.7) 70 (56.9) 0.66 1 0.416 No 2 (66.7) 1 (33.3) Type of latrine Open defecation 3 (100) 0 (0) 8.55 2 0.014 Pit latrine (unimproved) 0 (0) 6 (100) Pit latrine (improved) 52 (44.4) 65 (55.6) Stool disposal Open disposal/Thrown into garbage 19 (86.4) 3 (13.6) 25.06 2 < 0.001 Rinsed into toilet 18 (26.5) 50 (73.5) No children 18 (50.0) 18 (50.0) Handwash practice Regularly 31 (36.9) 53 (47.0) 5.23 1 0.022 Not regularly 24 (58.5) 17 (41.5) Presence of cross-connection Yes 55 (66.3) 28 (33.7) 50.56 1 < 0.001 No 0 (0) 43 (100) Note: Figures in parenthesis indicate the percentage of representative frequencies 3.2.3 Knowledge of cholera The table (Table 3 ) elaborated the distribution of knowledge gaps, misconception and preventive practices on cholera influencing the risk of cholera related to cases (n = 63) and controls (n = 63). Knowledge about cholera was higher among controls (58.6%) compared to cases (41.4%), but the difference was not statistically significant (p = 0.080). A small proportion of participants (7 cases vs.3 controls) reported having no knowledge at all. The correct knowledge of food and water as causes was significantly associated with lower cholera risk (p = 0.001). Misconceptions were evident where some participants attributed cholera to God, insects or fish (more common among controls), while others incorrectly cited bacteria/virus or gave no answer. Notably, 83.3% of cases who gave no answer were cholera patients. The recognition of watery diarrhea as the main symptom was common (41.5% cases than 58.5% controls), but not statistically significant (p = 0.108). Other symptoms such as vomiting, abdominal pain and fever were rarely mentioned, and many participants, particularly cases, gave no answer reflecting gaps in symptom recognition. Most of the participants identified contaminated food, water and unhygienic practices as transmission routes (45.5% cases than 54.5% controls). Misconception persisted since some of the participants believed that cholera spreads through person-to-person contact or polluted air. The knowledge on complications was statistically significantly associated with cholera risks (p = 0.030). Controls (65.8%) were more likely to recognize the complications compared to cases (34.2%). A large proportion of cases (59.0%) did not give answer, indicating poor knowledge of disease severity. The knowledge of preventive measures was significantly higher among controls (62.5%) compared to cases (37.5%) (p = 0.013). Lack of preventive knowledge was more common among cases (63.3%). The appropriate first action taken by the participants (giving ORS or visiting to health facility) was significantly associated with cholera risk (p < 0.001). The controls (62.8%) were more likely to take immediate action compared to cases (37.2%). About 13 cases (100%) reported doing nothing or waiting for severity, which reflects the hospitalization of the cases. Table 3 Frequency distribution and analysis of the knowledge of cholera among the participants Characteristics Case n (%) Control n (%) Chi-square value df p value Knowledge about cholera Yes 48 (41.4) 68 (58.6) 3.06 1 0.080 No 7 (70.0) 3 (30.0) Knowledge of causes of cholera Food/water 36 (43.9) 46 (56.1) 15.94 3 0.001 God/Insect/Fish 4 (16.7) 20 (83.3) Bacteria/Virus 5 (62.5) 3 (37.5) No answer 10 (83.3) 2 (16.7) Knowledge of main symptoms of cholera Watery diarrhea 44 (41.5) 62 (58.5) 7.59 4 0.108 Vomiting 2 (50.0) 2 (50.0) Abdominal pain 1 (16.7) 5 (83.3) Fever 1 (100) 0 (0) No answer 7 (77.8) 2 (22.2) Knowledge on transmission of cholera Contaminated food/water/unhygienic practices 40 (45.5) 48 (54.5) 6.139 3 0.105 Person-to-person contact 6 (42.9) 8 (57.1) Polluted air 0 (0) 7 (100) No answer 9(52.9) 8 (47.1) Knowledge of complications of cholera Dehydration/Death 26 (34.2) 50 (65.8) 7.00 2 0.030 Nothing happens 6 (54.5) 5 (45.5) No answer 23 (59.0) 16 (41.0) Knowledge on prevention of cholera Yes 36 37.5) 60 (62.5) 6.20 1 0.013 No 19 (63.3) 11 (36.7) First action taken in cholera Give ORS/visit to health facility 42 (37.2) 71 (62.8) 18.71 1 < 0.001 Do nothing/wait until severity 13 (100) 0 (0) 3.2.4 Underlying risk factors for cholera cases, OR with 95% CI The table below (Table 4 ) shows the underlying factors associated with cholera computed from binary logistic regression. The analysis revealed that adults aged 5–49 years were nearly three times more likely to be affected by cholera compared to other older adults (OR: 2.81, 95%CI: 1.15–6.92). The participants belonging to Muslim community was associated with markedly higher odds of cholera (OR: 12.26, 95% CI: 4.99–30.14). Illiteracy also emerged as a strong predictor, with almost 9 times increased risk (OR: 8.85, 95% CI: 2.58–30.47). Dietary practices like consumption of street food (OR: 11.47, 95% CI: 4,86-27.08) and raw food consumption (OR: 7.19, 95% CI: 3.23–16.01) were both strongly associated with cholera. The reliance of participants towards public tap water (OR: 19.77, 95% CI: 4.41–88.76) and pipe water (OR: 12.88, 95% CI: 2.31–72.02) showed higher odds than those who used handpump or deep boring water source. The participants drinking water without treatment were at the risk of (OR: 2.80, 95% CI: 1.33–5.92) than those who used any forms of drinking water treatment. Similarly, there was evidence of cross contamination with (OR: 2.46, 95% CI: 1.50–4.05). Sanitation and hygiene practice were equally important. Open disposal of children’s stool or throwing it in garbage was associated with an almost 18 times higher risk (OR: 17.59, 95% CI: 4.65–66.62). Irregular handwashing practice was twice the odds of cholera than those who washed their hands regularly (OR: 2.41, 95% CI: 1.13–5.18). Knowledge gaps also contributed to increasing risk of cholera among the participants. The participants who gave no answer regrading complications (OR: 2.76, 95% CI: 1.25–6.12) or those participants who had no knowledge on prevention (OR: 2.87, 95% CI: 1.23–6.73) were significantly more likely to be affected. Table 4 Underlying risk factors for cholera cases, OR with 95% CI S.N. Variables Cholera cases Crude OR 95% CI p value 1 Age 5–49 years 2.81 1.14–6.92 0.024 2 Ethnicity Muslim 12.26 4.98–30.14 < 0.001 3 Education Illiteracy 8.85 2.57–30.46 0.001 4 Street food consumption Yes 11.47 4.86–27.07 < 0.001 5 Raw food consumption Yes 7.19 3.23–16.01 < 0.001 6 Main source of drinking water Public tap 19.77 4.40-88.76 < 0.001 Pipe water 12.88 2.30-72.01 0.004 7 Drinking water treatment No 2.80 1.33–5.91 0.007 8 Presence of cross connection Yes 2.46 1.49–4.04 < 0.001 9 Stool disposal of children Open disposal/thrown in garbage 17.59 4.64–66.61 < 0.001 10 Handwashing practice Not regularly 2.41 1.12–5.17 0.024 11 Knowledge of complications of cholera Nothing happens 2.30 0.64–8.28 0.200 No answer 2.76 1.24–6.12 0.012 12 Knowledge on prevention of cholera No 2.87 1.23–6.73 0.015 3.3 Information on preventive and control measures from literature review The unmatched case-control study conducted to describe the outbreak, determine its source and risk factors and institute control measures to guide effective prevention and containment strategies provided the intervention including community education, personal hygiene and sanitation programs were emphasized as public health intervention ( 15 ). The unmatched case-control study conducted to assess the determinants of cholera outbreak in sub-city of Shaggar, Oromia, Ethiopia with 1:2 case to control ratio among 60 cases and 120 controls by using structured questionnaire guided with health education, chlorination of water, strengthening surveillance were implemented. To reduce the risk of future outbreak of cholera, environmental hygiene, practices and the use and accessibility of safe drinking water were interventions to promote at community level ( 16 ). The active surveillance of cholera outbreak study conducted in town administrative of Guraghe zone of Ethiopia to assess the cholera outbreak, its challenges, and the way forward on public health intervention to solve the knowledge and health services delivery gap related to cholera control concluded that to control cholera outbreak oral cholera vaccination, long-term intervention i.e. WASH measures to ensure safe water and good hygiene practices, early diagnosis and treatment were regarded as the effective measures to prevent and control the disease outbreak ( 17 ). A retrospective epidemiological study was conducted among 1997 cholera cases to analyze the 2023 cholera outbreak in Sudan and to recommend prevention and control measures in Gadarif State, Sudan concluded that the need of laboratory and epidemiologic surveillance and educational activities to address myths and misconception among community people were the major interventions recommended ( 12 ). The unmatched case-control study conducted among the person aged more than 5 years with acute watery diarrhea in Gomai community with a total of 43 cases and 68 controls suggested that controlling cholera outbreaks requires strong surveillance and rapid response system. For sustainable control, a broader economic development on universal access to safe drinking water and proper sanitation and waste management were recommended. Alongside, oral cholera vaccines were recommended for effective preventive measures ( 18 ). From the most selected literature, the study has pointed out few effective preventive measures based on the priority: Strengthening surveillance and rapid response Ensuring WASH practices Enhancing community education and behavioral change Initiating oral cholera vaccination Strengthening early diagnosis and treatment 4 DISCUSSION The findings of the study provide insight into the dynamics of cholera outbreaks, showing how demographic, environmental, behavioral and knowledge-related factors interact to shape vulnerability. Although the overall attack rate was relatively low 0.74% and no fatalities were recorded, the clustering of cases in wards 11–14, with ward 13 reported the highest burden. Such disproportionate patterns in the burden of disease recall the need for surveillance system that can detect and respond rapidly at the community level. The fatality rates varied across different studies; Torokaa et al (2025) observed 3.5%, Berhe and EI Bushra (2024) reported 2.6% and Asantewaa’s meta-analysis found a pooled rate of 1.3% across low-middle income countries. These differences reflect variations in outbreak severity, health system capacity and timeliness of interventions. In the study, participants aged 5–49 years were nearly three times more likely to have increased risk of cholera compared to older adults. This finding resonates with Torokaa at al. (2025), who reported that individuals below 25 years had over 4 times higher odds of cholera. Younger populations are often more exposed to school environments, dietary habits and ignorance on hygiene maintenance. The gender did not show any association in the study however, Torokaa found more than half of cases were female, suggesting that gender roles in food preparation, water collection and caregiving may contribute to exposure. Ethnicity and education were the social determinants in the study. The finding revealed that cholera is not just a waterborne disease but also associated with social factors. The dietary and water-related practices were equally contributing to the increased risk of cholera. Street food consumption was strongly associated with cholera in the study. The participants who consumed food outside the home were 11 times higher at the risk of cholera. Raw food consumption including raw vegetables and meat also increased risk significantly. These findings align with the Torokaa and Mideska (2024), who identified eating outside the home and poor sanitation in food establishments as major contributors. The participants, depending on public taps and untreated water along with cross connections in water supply, were critical hazards in the study. Similar challenges were reported by Mideska in Ethiopia, where safe water sources and poor latrine conditions increased risk and by Berhe et al. (2024), who highlighted inaccessible safe water and low latrine coverage as persistent barriers. Sanitation and hygiene practices further shaped outcomes. Improper disposal of children’s’ stool was associated with an almost 17 times higher odds of risk of cholera than those who rinsed into toilet, while irregular handwashing doubled the odds of cholera. Although latrine availability itself was not significant, the type of latrine mattered with open defecation exclusively reported among the cases. These findings were like Berhe et al who emphasized the need for improved latrine coverage and utilization. The gaps in knowledge played a critical role in increasing the risk of cholera. Many cases of the study were unable to recognize complications of cholera and lacked preventive measures and significance of prompt treatment from health facility. Misconceptions persisted among the participants on the cholera transmission as God/insect/fish. Like the study, Bushra et al (2024) found that myths about the water chlorination hindered outbreak control in Sudan. Limitations of the study Despite visible cross connections in the water supply, researchers were not permitted to collect or conduct clinical water tests which prevented confirmation of V. cholerae contamination and weakened the ability to establish direct environmental factors. Different socioeconomic and age variations in the unmatched case-control study may have influenced the associations. However, the study has gathered information directly from the community people, ensuring the relevant of the data. 5 CONCLUSION The unmatched case-control study was conducted among the participants of Birgunj during the cholera outbreak. The major findings of the study identified multiple socio-demographic and behavioral risk factors significantly associated with cholera. The participants aged 5–49 years, individuals from Muslim ethnic groups and those who were illiterate faced markedly higher odds of risk of cholera. Unsafe food practices and poor water and sanitation behaviors further elevated risk. Lack of awareness about cholera complications and preventive measures also contributed to vulnerability, overall, cholera risk was strongly linked to age, ethnicity, family type, food and water hygiene, sanitation practices and knowledge gaps. Abbreviations CDC Centers for Disease Prevention and Control CI Confidence Interval EDCD Epidemiological Disease Control Department FCHV Female Community Health Volunteers HDU High Dependency Unit IBM SPSS Statistical Package for the Social Sciences ICU Intensive Care Unit OR Odds Ratio ORS Oral Rehydration Salt U.S. United States WASH Water, Sanitation and Hygiene WHO World Health Organization Declarations Ethical approval and consent to participate Ethical approval was obtained from Institutional Review Committee (IRC) of Pokhara University and an approval letter from the public health office was obtained before data collection. Consent for publication The written and verbal consent was taken, and confidentiality was ensured by each participant in the study. If the participant was below 18 years of age, the written consent from their guardian or caretaker was obtained. Availability of data and materials The dataset generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no conflict of interest. Funding No fundings were provided. Authors’ Contributions DPP supervised entire study and guided the team throughout the study. NS supported by carefully validating the data and guiding the analysis. The authors (DCT, JK, PP, RS, SS) have equally contributed to the study from the time of proposal development, tool design and translation, data collection and analysis and preparing the manuscript. Acknowledgments We show our gratitude to Mr. Raju Sah, Health Coordinator/ Head of Health Division, Birgunj metropolitan city and other staff who provided access to data and helped us during the fieldwork to help identify households. Their cooperation made the challenging parts of this study much smoother. We are grateful to each person who contributed their time and efforts. References Zheng Q, Luquero FJ, Ciglenecki I, Wamala JF, Abubakar A, Welo P, et al. Cholera outbreaks in sub-Saharan Africa during 2010–2019: a descriptive analysis. Int J Infect Dis. 2022 Sept;122:215–21. CDC. Cholera global snapshot [Internet]. U.S. Centers for Disease Control and Prevention; 2025 [cited 2025 Aug 28]. Available from: https://www.cdc.gov/cholera/about/global-epidemiology-of-cholera.html NICD. Cholera global and southern Africa update. (April 2025) [Internet]. National Institute for comunicable diseases; 2025 [cited 2025 Aug 28]. Available from: https://www.nicd.ac.za/cholera-global-and-southern-africa-update-april-2025/ ECDC. Cholera worldwide overview [Internet], European Center for Disease Prevention and Control. 2025. Available from: https://www.ecdc.europa.eu/en/all-topics-z/cholera/surveillance-and-disease-data/cholera-monthly Qaserah AM, Amad MAA, Serouri AAA, Khader YS. Risk factor of cholera transmission in AI Hudaydah, Yemen: Case-Control study. JMIR Public Health Surveill [Internet]. 2021 July 5;7(7). Available from: https://publichealth.jmir.org/2021/7/e27627/ Subedee KC, Paudel KP, Pandey HR, Chaudhary M, Kandel S, Pradhan M, et al. Epidemiological investigation of a cholera outbreak in Nepal–India border communities: Public health implications. IJID Reg. 2025;14:100489. Dinede G, Abagero A, Tolosa T. Cholera outbreak in Addis Ababa, Ethiopia: A case-control study. PLOS One [Internet]. 2020 July 2; Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0235440 Thakur M. Birgunj sees mass outbreak spreads. Republica [Internet]. I. 2025; Available from: https://myrepublica.nagariknetwork.com/news/birgunj-sees-mass-exodus-as-cholera-outbreak-spreads-14-98.html Poudel A, Acharya S. Birgunj cholera outbreak largest since Jajarkot in. 2009. The Kathmandu Post [Internet]. 2025; Available from: https://kathmandupost.com/health/2025/08/25/birgunj-cholera-outbreak-largest-since-jajarkot-in-2009 EDCD. Situation update on cholera outbreak [Internet]. Ministry of Health and Population; 2025 [cited 2025 Aug 28]. Available from: https://edcd.gov.np/uploads/news/pdf/68aed1c13a0cb.pdf NRCS. NRCS responds to cholera outbreak in Birgunj. Ratopati [Internet]. 2025 Aug 27 [cited 2025 Aug 28]; Available from: https://english.ratopati.com/story/40613 El Bushra HE, Haroun AAA, Alkhidir MA, Banaga AO, Elbushra HA, Osman NAN, et al. Retrospective analysis of a large-scale cholera outbreak in Sudan. East Mediterr Health J. 2024;30(10):698–703. THT. Ministers discuss ways to control cholera outbreak in Birgunj. The Himalayan Times [Internet]. 2025; Available from: https://thehimalayantimes.com/nepal/ministers-discuss-ways-to-control-cholera-outbreak-in-birgunj Subedee KC, Paudel KP, Pandey HR, Chaudhary M, Kandel S, Pradhan M, et al. Epidemiological investigation of a cholera outbreak in Nepal–India border communities: Public health implications. IJID Reg. 2025;14:100489. Torokaa PR, Njau A, Kimambo J, Urio L, Muchunguzi V, Makala R, et al. Cholera outbreak in Hanang District, Manyara, Tanzania, July 2024: An unmatched case-control study. J Interv Epidemiol Public Health. 2025;8(2):1–17. Mideksa G, Botore A, Abdo B. Investigation of cholera outbreak and its determinants in Shaggar city, Oromia, Ethiopia, 2024: a case-control study [Internet]. In Review; 2024 [cited 2025 Aug 28]. Available from: https://www.researchsquare.com/article/rs-4483047/v1 Berhe TM, Fikadu Y, Sahle T, Hailegebireal AH, Eanga S, Ketema T, et al. Existence of cholera outbreak, challenges, and way forward on public health interventions to control cholera outbreak in Guraghe Zones, southern Ethiopia, 2023. Front Public Health. 2024;12:1–9. Dan-Nwafor CC, Ogbonna U, Onyiah P, Gidado S, Adebobola B, Nguku P, et al. A cholera outbreak in a rural north central Nigerian community: an unmatched case-control study. BMC Public Health. 2019;19(1):112. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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10:10:17","extension":"html","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127480,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/b47fad0e87b1a396e4196b96.html"},{"id":98765172,"identity":"b924b7aa-542d-4a2d-add7-edbd3e735453","added_by":"auto","created_at":"2025-12-22 10:10:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160207,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/8f2d680547a104695de8d985.png"},{"id":98765200,"identity":"00338c6f-b91d-4896-b3bc-d36b6ef0cf2d","added_by":"auto","created_at":"2025-12-22 10:10:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90083,"visible":true,"origin":"","legend":"\u003cp\u003eEpidemic curve showing cases of cholera reported in Birgunj sub-metropolitan health office of Birgunj, Nepal (August 12-September 7, 2025) (n=1154)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/6b65c6788cf3227dba0deda9.png"},{"id":98765206,"identity":"90084a45-2032-4baf-8400-feffbedfbe8c","added_by":"auto","created_at":"2025-12-22 10:10:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115628,"visible":true,"origin":"","legend":"\u003cp\u003eAge and sex wise distribution of acute gastroenteritis/ possible cholera cases in Birgunj (Till August 29, 2025) (n=693)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/0d346b8ad108a23f8437bc42.png"},{"id":98765177,"identity":"0b89c0b6-ac9f-4f7a-bda3-d003d827f653","added_by":"auto","created_at":"2025-12-22 10:10:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":105119,"visible":true,"origin":"","legend":"\u003cp\u003eWard wise distribution of cholera cases in Birgunj (till August 29, 2025) (n=693)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/d5857804ec542ba986d95810.png"},{"id":98765179,"identity":"dd9992b3-6f3b-48c2-9ffd-e486ae788c0e","added_by":"auto","created_at":"2025-12-22 10:10:16","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":132730,"visible":true,"origin":"","legend":"\u003cp\u003eAdmission wise cholera case distribution except ward 11, 12, 13, 14 in Birgunj (August 18-29, 2025) (n=195)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/9b181c0dcd7c55b7809e77bb.png"},{"id":98765194,"identity":"93b6d331-1086-4bad-89db-d3f836db8553","added_by":"auto","created_at":"2025-12-22 10:10:17","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":169835,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of cases in ICU, HDH and general wards of hospital, Birgunj (till August 29, 2025)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/ef4ee2edd6570cc4c1c0b809.png"},{"id":104691890,"identity":"49ac4c09-91bb-4366-b824-962e84516b27","added_by":"auto","created_at":"2026-03-16 06:26:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2230356,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8386341/v1/0c201202-55f1-4c09-8c53-da590e1d6144.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outbreak investigation of cholera in Birgunj, Nepal: An unmatched case-control study","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eCholera still poses a serious public health threat globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). U.S. Centers for Disease Prevention and Control (CDC) claimed that cholera is responsible to kill tens of thousands of people around the world every year (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to WHO, 804,721 cholera cases and 5,805 deaths were reported across 33 counties of five WHO regions in 2024. By the end of first quartile 2025, 25 countries had reported cholera or acute watery diarrhea with 116,574 cases and 1,514 deaths mostly from Africa, Eastern Mediterranean and Sout-East Asia (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Based on the information of European Centers for Disease Prevention and Control, since March 17, 2025 about 16,111 new cholera cases with 372 new deaths have been reported worldwide and these new cases were from Asian and African countries including Afghanistan, Bangladesh, India, Nepal and others (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCholera is an extremely virulent disease of inequality that cases severity among poor and the most vulnerable people. Approximately 3\u0026ndash;5\u0026nbsp;million people worldwide suffer from cholera with more than 100,000 deaths. Particularly, it spreads in places where living conditions are difficult with lack of safe drinking water and improper sanitation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Around 60 percent of population are at risk of diarrheal disease outbreak due to persistent socio-economic issues like poverty, poor sanitation and weak infrastructure in Nepal (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The study conducted by have shown that the most known risk factors for cholera outbreak are contaminated water sources, unwashed raw vegetables, lack of adequate latrines and heavy rainfall and floods (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). It is necessary to identify the sources and associated risk factors of cholera outbreak in developing countries like Nepal.\u003c/p\u003e \u003cp\u003eOn 22nd August 2025, the Epidemiological Disease Control Department (EDCD) notified the sudden rise of acute watery diarrhea from health facilities in multiple wards including 3, 11, 12, 13, 14 and 16 of Birgunj metropolitan city, confirming cholera outbreak. Several activities were conducted in the outbreak areas including over 300 patients were treated across different hospitals, free treatment were provided through public and private hospitals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Rapid diagnostic tests and lab confirmation were done along with water samples testing by World Health Organization(WHO) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The recent data showed that out of 540 cases, 257 cases were recovered, and 283 cases were active cases (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Different public health measures like awareness campaigns on hygiene and safe water practices, distribution of ORS packets and door-to-door outreach for hygiene promotion were conducted by different organizations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough cholera is predictable, preventable and treatable, it continues to spread widely across the different areas of the nation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The recent outbreak of Birgunj has been marked as one of Nepal\u0026rsquo;s most significant public health emergencies since Jajarkot epidemic of 2009 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The outbreak is so rapid that it has affected over 300 individuals being hospitalized within days with multiple requirements of intensive care. On the other hand, despite Nepal\u0026rsquo;s declaration of being open-defecation-free in 2019, the outbreak highlighted that it is a critical failure in water safety and sanitation infrastructure. One of thearticles revealed that those patients admitted to hospitals had low awareness and delayed care-seeking behavior, causing a great barriers to early treatment (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost of the cholera outbreak investigation in Nepal have focused on patients who reach health facilities, with much of the research concentrated in Kathmandu valley. This pattern likely reflects weak surveillance system and limited diagnostic capacity in rural areas. In contrast, during 2025 outbreak in Birgunj, multiple external development partners and local government worked together to combat the outbreak (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, to visualize and understand the real scenario of the cholera outbreak the study was conducted to identify the risk factors of cholera outbreak and explore preventive and control measures in later years.\u003c/p\u003e"},{"header":"2. METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThe population-based unmatched case control study with a 1:1 case-control ratio to identify the risk factors for cholera transmission was used. The one control over a case was used due to resource constraints. According to EDCD, multiple wards; 11, 12 and 13 of Birgunj metropolitan city were highly affected by cholera outbreak.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Case and control identification and recruitment process\u003c/h2\u003e \u003cp\u003eBased on the nature of the outbreak, confirmed cases were those people or patient aged five years and above with laboratory diagnosed with \u003cem\u003eV. cholerae\u003c/em\u003e from specimen culture from August 22, 2025. The population control was those people living in the same community who had no history of diarrhea since last five days before August 22, 2025. The control can be either the people of the same household or neighbors of confirmed cases. The information on the confirmed cases was obtained from the Public Health Office, Birgunj, hospitals and health office. All the confirmed cases were tracked. The information on confirmed cases\u0026rsquo; names (only for purpose of tracking the case and later it was coded for confidentiality), address, contact details along with the FCHVs of those confirmed communities/wards were also listed accordingly. The controls were selected based on the household or neighbor of case, all the eligible members were listed and those who were able to answer questions of questionnaire and those who were willing to participate were selected. The number of controls from each case household was one based on the case-control ratio distribution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Sample size calculation\u003c/h2\u003e \u003cp\u003eAt first, being the study case control, the sample size determination was initially formulated from the formula; n=(zα/2\u0026thinsp;+\u0026thinsp;zβ)\u003csup\u003e2\u003c/sup\u003e p(1-p) (r\u0026thinsp;+\u0026thinsp;1)/d\u003csup\u003e2\u003c/sup\u003er where, zα/2 is assumed 1.96 at 95% CI, zβ is assumed 0.84 at 80% power, p is 0.03 attack rate, r is 1 and d is calculated to be 0.17 (from the formula; d\u0026thinsp;=\u0026thinsp;p-p\u003csub\u003e1\u003c/sub\u003e where p\u003csub\u003e1\u003c/sub\u003e is formulated from the formula, p\u003csub\u003e1=\u003c/sub\u003e p (OR)/1\u0026thinsp;+\u0026thinsp;p (OR-1) where the odds ratio was 2.0. These parameters (including odds ratio, attack rate, p value) were taken from the study conducted by Subedee et al (2025). We calculated sample size to be 126 where 63 cases and 63 controls were taken. Regarding the selection of wards, after visiting the field and reviewing reports, the wards with high number of cases were identified in wards 11, 12 and 13. That is why, the sample units were taken from these wards.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Research tools and techniques\u003c/h2\u003e \u003cp\u003eThe face-to-face interview was conducted among the cases and controls enrolled in the study based on the structured questionnaire. The questionnaire was prepared referring to the WHO guidelines on cholera outbreak investigation and later translated into Nepali language. The time required to interview cases and controls was approximately 15\u0026ndash;30 minutes. For identifying the status of cholera outbreak, data from the sub-metropolitan health office, Birgunj was taken. To explore the preventive and control measures, various literatures from the published similar study design articles were collected and among all the suitable and effective measures were enlisted in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data analysis procedure\u003c/h2\u003e \u003cp\u003eThe primary data were collected from the interview with confirmed cases and controls of wards 11, 12 and 13 whereas, the secondary data including the number of new confirmed cases and suspected cases based on wards, hospital admission, treatment from Birgunj metropolitan health office were collected from August 20, 2025, to September 14, 2025. With the help of MS-Excel and IBM SPSS version 21, the data was managed and analyzed. MS-Excel was used for data coding and data entry. Later the exported data were analyzed in SPSS. The descriptive statistics like frequency distribution, designing epidemic curve and determining attack rate, case fatality rate were computed and visualized in graphs. All the categorical explanatory variables were cross tabulated with the dependent variable and described in terms of frequency and proportion, for case and control groups. To identify whether the independent variables are statistically significant with dependent variable, chi-square test was computed at p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and binary logistic regression was assessed to find out the crude odds ratio with 95% confidence intervals. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistical significance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Study variables\u003c/h2\u003e \u003cp\u003eFrom the rigorous literature review, the explanatory/exposure variables included in the study were demographic and socio-economic factors (age, gender, ethnicity, main source of income, educational qualification, family type), WASH associated factors (street food consumption and hygiene maintenance, raw food consumption, main source of drinking water, experience of water shortage, drinking water treatment methods, availability of latrine/toilets and its type, child stool disposal practice, handwash practice and presence of cross connection) and knowledge related factors (about cholera, its causes, main symptoms, mode of transmission, complications, preventive measures and first control action to be taken).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe figure above (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) shows the core structure of case-control study on cholera, comparing individuals with confirmed cholera (Cases) to those without the disease (controls). Both groups are assessed for exposure to potential risk factors such as unsafe water or poor sanitation and then categorized as exposed and non-exposed. This design helps to identify which exposures are more common among cases, guiding targeted public health interventions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperational definition\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCase\u003c/strong\u003e \u003cp\u003eThose people or patient aged five years and above with laboratory diagnosed with \u003cem\u003eV. cholerae\u003c/em\u003e from specimen culture from August 22, 2025.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eControl\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThose people living in the same community had no history of diarrhea since last five days before August 22, 2025. The control can be either the people of the same household or neighbors of confirmed cases.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWard definition\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe grassroot level, representing administrative units of local government under municipality and rural municipalities. In the study area, there were 32 wards in Birgunj metropolitan city, from where the study selected three wards i.e. ward 11, 12 and 13 having highest cases of cholera.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEducational qualification\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe educational qualification was broadly categorized into illiterate, who were unable to read and write and also included those participants who had received informal education and are able to write their names, primary level indicating those people who had completed their formal education till grade 5, secondary level included participants completing their formal education till grade 10, diploma/bachelor included 11, 12 or 3 years course completion after grade 10 and higher studies. .\u003c/p\u003e \u003cp\u003e \u003cb\u003eHygiene maintenance on street food consumption\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe good hygiene of street foods was assessed based on the clean-washed utensils used, a stall inside a concrete house, a food seller using gloves and serving in paper or plastic disposal utensils. In contrast to it, poor hygiene included presence of pests and flies around the foods, uncovered foods, stall at open space, open ground, or near school gates, food seller not using gloves, serving food in the same utensils by simply washing it with water and uncovered water storage to wash utensil.\u003c/p\u003e \u003cp\u003e \u003cb\u003eHandwashing practice\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe participants who practice regular handwashing with clean running water and proper soap at all critical times as recommended by WHO i.e. after using toilet, before preparing or cooking food, before eating or feeding others, after contact with any contamination source (handling water, cleaning, touching animals, coughing/sneezing) whereas, not regularly is considered as not washing hands consistently or only occasionally (not practicing handwash after toilet or before food preparation), only with water (skipping handwash with soap).\u003c/p\u003e \u003cp\u003e \u003cb\u003ePresence of cross connection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe unsafe link between drinking water system and contaminated sources including sewage or drainage lines in home and public taps.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 RESULTS","content":"\u003cp\u003eDuring the field visit to Birgunj, secondary data from the sub-metropolitan health office was collected to determine the number of reported cholera cases. In addition, community-based data was collected. Therefore, this section is broadly categorized into results derived from health care facilities and findings from the empirical study.\u003c/p\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e3.1 Health facility case review\u003c/h2\u003e\n \u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3.1.1 Epidemic Curve of cholera outbreak\u003c/h2\u003e\n \u003cp\u003eAs shown in the epidemic curve (Fig. 2), the number of new cases of cholera changed every day in Birgunj over 26-day period. For the first 10 days, the situation was normal with cases mostly between 1 and 11. However, on August 22, there was a sharp increase, including 43 cases. In August 23, cases reached 82, a dramatic spike. The peak was on August 27, 2025, with 106 cases which is the highest cases in the entire period. After the intervention and control measures were applied due to which the cases began to drop from 84 on August 28 to 36 on September 6, 2025.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.1.2 Attack rate of cholera\u003c/h2\u003e\n \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n \u003cdiv\u003eThe total number of new cases during the outbreak (from August 22, 2025, till September 7, 2025) was 989 and the population at risk during the outbreak (Population of Birgunj sub-metropolitan city during the outbreak according to sub-metropolitan health office) was 133238 so the attack rate was 0.74%.\u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e3.1.3 Case fatality rate\u003c/h2\u003e\n \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n \u003cp\u003eThe number of deaths due to cholera during the outbreak was 0 and the number of confirmed cases from August 22, 2025, to September 7, 2025, was 1114 so the case fatality rate was 0 per 100 population.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003e3.1.4 Age-Sex wise number of acute gastroenteritis/ possible cholera cases\u003c/h2\u003e\n \u003cp\u003eThe figure (Fig. 3) shows the number of female and male across different age groups in a population with acute gastroenteritis or possible cholera cases in Birgunj during cholera outbreak. It shows that there was early exposure of disease among the children aged 0–4 years i.e. 19 among female and 15 among male. The most affected age group were 15–24 years, similarly age group 25–54 years were affected. There was decline among the old adults aged 55 and above.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003e3.1.5 Ward wise distribution of cholera\u003c/h2\u003e\n \u003cp\u003eThe figure (Fig. 4) shows the ward-wise distribution of 693 cholera cases in Birgunj sub-metropolitan city up to August 29, 2025. Ward 12 is the epicenter, with a dramatic increase of 135 cases, indicating a major outbreak cluster followed by ward 13 with 98 cases and ward 11 with 65 cases indicating high transmission in these clusters. Wards 1–10 and 16–32 show low case counts, mostly below 20, with many wards reporting fewer than 5 cases. The curve shows a sharp rise from ward 10 to ward 12, followed by gradual decline, resembling a localized outbreak curve.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003e3.1.6 Number of hospitalized cholera cases, Birjung\u003c/h2\u003e\n \u003cp\u003eThe figure above (Fig. 5) shows the number of cholera admissions per day among 195 cases, excluding wards 11–14. These wards were excluded because there were no hospitalized cholera cases from these wards. Although wards 11–14 were excluded, the figure shoed a secondary rapid increase in other wards. Due to increased community awareness and reporting, expansion of surveillance and testing, the admission pattern reached its peak on August 26 with 38 cases admitted to hospitals. From August 27, admissions declined steadily.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003e3.1.7 Number of cases in ICU, HDU and general wards, Birjung\u003c/h2\u003e\n \u003cp\u003eThe figure above (Fig. 6) shows the number of cholera cases admitted to ICU, HDU and general wards in Birgunj hospital from August 24 to August 29, 2025. Most cholera patients were admitted to the general ward, peaking at 232 cases on August 27. This reflects most of the cases were managed with ORS, IV fluids and basic monitoring. ICU cases increased from 22 to 35, indicating a growing number of severe cases requiring intensive care. HDU cases remained low (1–6 per day), suggesting limited use or capacity.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003e3.2 Information from the case-control study\u003c/h2\u003e\n \u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003e3.2.1 Socio-demographic characteristics\u003c/h2\u003e\n \u003cp\u003eThe table below (Table 1) shows the comparison of 63 cases and 63 controls across various demographic and socio-economic characteristics. The Chi-square test is used to assess whether differences between groups are statistically significant. A p-value \u0026lt; 0.05 indicates a meaningful association.\u003c/p\u003e\n \u003cp\u003eAs shown in the figure, majority of cases were from the age group 5–49 years. Among them 49.5% were cases and remaining were control. The data showed that there was statistically significant association with age. Cholera cases were less common among older adults.\u003c/p\u003e\n \u003cp\u003eThe cholera case was common among female participants than male. There was no statistically significant difference though slightly more females were affected. Talking about the ethnicity, in the study area comprised exclusively Hindu and Muslim communities, with no representation from other religious groups. There was highly statistically significant difference between the ethnicity where Muslims were disproportionately affected compared to Hindus. The main source of income among the participants was business, alongside those participants with source of income as service were higher among the controls with 66.7%. There was no significant difference across the main source of income. There was strong association between education and cholera cases where illiteracy was more common among cases. Similarly, the family type did not show the significant association between cholera.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency distribution and analysis of socio-demographic characteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-square value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eAge (Years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (50.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.323\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (25.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (74.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (48.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHindu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (85.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e35.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (32.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain source of income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgriculture/Daily wage labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e4.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (62.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService (private/government)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood vendor/Street food seller\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (56.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e22.982\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary level (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (32.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary level (\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma and higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (87.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.438\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint/Extended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (52.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Figures in parenthesis indicate the percentage of representative frequencies\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Factors associated with Water, Sanitation and Hygiene (WASH)\u003c/h2\u003e \u003cp\u003eThe table (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) shows the patterns and significant associated factors of cholera by comparing cases (n\u0026thinsp;=\u0026thinsp;63) and control (n\u0026thinsp;=\u0026thinsp;63). As shown in the table, street food consumption was strongly associated with cholera (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). A higher proportion of cases (69.2%) consumed street food compared to controls (30.8%) t. Similarly, raw food consumption like meat and vegetables also showed a significant association (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Cases (65.6%) were more likely to consume raw food compared to control (34.4%). However, hygiene maintenance of street food did not show statistical significance though poor hygiene was more common among cases.\u003c/p\u003e \u003cp\u003eThe main source of drinking water was significantly associated with cholera (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). cases were more likely to rely on public taps (57.7%) compared to controls, while control more often used handpumps or deep boring (93.5%). Only 29.6% of cases treated their water compared to 70.4% of controls (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003eThe type of latrine showed a significant association (p\u0026thinsp;=\u0026thinsp;0.0014). All individuals practicing open defecation were cases, while unimproved pit latrines were only reported among controls. Improved pit latrines were more common in both groups.\u003c/p\u003e \u003cp\u003eHandwashing practice was significantly associated with cholera (p\u0026thinsp;=\u0026thinsp;0.022). Not washing hands regularly was more common among cases (58.5%) compared to controls (41.5%). The presence of cross connection in water supply showed a very strong association (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All controls reported no cross-connection, while 66.3% of cases had cross-connections in their water supply.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency distribution and factors associated with cholera with water, sanitation and hygiene\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-square value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eStreet food consumption\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e35.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (83.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHygiene maintenance of street food\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor hygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (52.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood hygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDon\u0026rsquo;t eat outside\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRaw vegetables and meat consumption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e25.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (21.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (79.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain source of drinking water\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePipe water into dwelling/yard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e23.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic tap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (42.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHandpump or deep boring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (93.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExperience of water shortage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (57.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDrinking water treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (70.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLatrine availability\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of latrine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen defecation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e8.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePit latrine (unimproved)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePit latrine (improved)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (55.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStool disposal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen disposal/Thrown into garbage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (86.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e25.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRinsed into toilet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (73.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHandwash practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegularly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (47.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot regularly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (41.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of cross-connection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e50.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Figures in parenthesis indicate the percentage of representative frequencies\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Knowledge of cholera\u003c/h2\u003e \u003cp\u003eThe table (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) elaborated the distribution of knowledge gaps, misconception and preventive practices on cholera influencing the risk of cholera related to cases (n\u0026thinsp;=\u0026thinsp;63) and controls (n\u0026thinsp;=\u0026thinsp;63). Knowledge about cholera was higher among controls (58.6%) compared to cases (41.4%), but the difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.080). A small proportion of participants (7 cases vs.3 controls) reported having no knowledge at all. The correct knowledge of food and water as causes was significantly associated with lower cholera risk (p\u0026thinsp;=\u0026thinsp;0.001). Misconceptions were evident where some participants attributed cholera to God, insects or fish (more common among controls), while others incorrectly cited bacteria/virus or gave no answer. Notably, 83.3% of cases who gave no answer were cholera patients.\u003c/p\u003e \u003cp\u003eThe recognition of watery diarrhea as the main symptom was common (41.5% cases than 58.5% controls), but not statistically significant (p\u0026thinsp;=\u0026thinsp;0.108). Other symptoms such as vomiting, abdominal pain and fever were rarely mentioned, and many participants, particularly cases, gave no answer reflecting gaps in symptom recognition. Most of the participants identified contaminated food, water and unhygienic practices as transmission routes (45.5% cases than 54.5% controls). Misconception persisted since some of the participants believed that cholera spreads through person-to-person contact or polluted air.\u003c/p\u003e \u003cp\u003eThe knowledge on complications was statistically significantly associated with cholera risks (p\u0026thinsp;=\u0026thinsp;0.030). Controls (65.8%) were more likely to recognize the complications compared to cases (34.2%). A large proportion of cases (59.0%) did not give answer, indicating poor knowledge of disease severity. The knowledge of preventive measures was significantly higher among controls (62.5%) compared to cases (37.5%) (p\u0026thinsp;=\u0026thinsp;0.013). Lack of preventive knowledge was more common among cases (63.3%).\u003c/p\u003e \u003cp\u003eThe appropriate first action taken by the participants (giving ORS or visiting to health facility) was significantly associated with cholera risk (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The controls (62.8%) were more likely to take immediate action compared to cases (37.2%). About 13 cases (100%) reported doing nothing or waiting for severity, which reflects the hospitalization of the cases.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency distribution and analysis of the knowledge of cholera among the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChi-square value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eKnowledge about cholera\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (41.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (58.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (30.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of causes of cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood/water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e15.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGod/Insect/Fish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBacteria/Virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of main symptoms of cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWatery diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (58.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e7.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge on transmission of cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContaminated food/water/unhygienic practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e6.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerson-to-person contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolluted air\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge of complications of cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDehydration/Death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNothing happens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (59.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (41.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge on prevention of cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (36.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFirst action taken in cholera\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGive ORS/visit to health facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (62.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e18.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo nothing/wait until severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4 Underlying risk factors for cholera cases, OR with 95% CI\u003c/h2\u003e \u003cp\u003eThe table below (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) shows the underlying factors associated with cholera computed from binary logistic regression. The analysis revealed that adults aged 5\u0026ndash;49 years were nearly three times more likely to be affected by cholera compared to other older adults (OR: 2.81, 95%CI: 1.15\u0026ndash;6.92). The participants belonging to Muslim community was associated with markedly higher odds of cholera (OR: 12.26, 95% CI: 4.99\u0026ndash;30.14). Illiteracy also emerged as a strong predictor, with almost 9 times increased risk (OR: 8.85, 95% CI: 2.58\u0026ndash;30.47).\u003c/p\u003e \u003cp\u003eDietary practices like consumption of street food (OR: 11.47, 95% CI: 4,86-27.08) and raw food consumption (OR: 7.19, 95% CI: 3.23\u0026ndash;16.01) were both strongly associated with cholera. The reliance of participants towards public tap water (OR: 19.77, 95% CI: 4.41\u0026ndash;88.76) and pipe water (OR: 12.88, 95% CI: 2.31\u0026ndash;72.02) showed higher odds than those who used handpump or deep boring water source. The participants drinking water without treatment were at the risk of (OR: 2.80, 95% CI: 1.33\u0026ndash;5.92) than those who used any forms of drinking water treatment. Similarly, there was evidence of cross contamination with (OR: 2.46, 95% CI: 1.50\u0026ndash;4.05).\u003c/p\u003e \u003cp\u003eSanitation and hygiene practice were equally important. Open disposal of children\u0026rsquo;s stool or throwing it in garbage was associated with an almost 18 times higher risk (OR: 17.59, 95% CI: 4.65\u0026ndash;66.62). Irregular handwashing practice was twice the odds of cholera than those who washed their hands regularly (OR: 2.41, 95% CI: 1.13\u0026ndash;5.18). Knowledge gaps also contributed to increasing risk of cholera among the participants. The participants who gave no answer regrading complications (OR: 2.76, 95% CI: 1.25\u0026ndash;6.12) or those participants who had no knowledge on prevention (OR: 2.87, 95% CI: 1.23\u0026ndash;6.73) were significantly more likely to be affected.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnderlying risk factors for cholera cases, OR with 95% CI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eS.N.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c3\" namest=\"c2\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eCholera cases\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrude OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;49 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.14\u0026ndash;6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.98\u0026ndash;30.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIlliteracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.57\u0026ndash;30.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStreet food consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.86\u0026ndash;27.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRaw food consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.23\u0026ndash;16.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMain source of drinking water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic tap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.40-88.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePipe water\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.30-72.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrinking water treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.33\u0026ndash;5.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresence of cross connection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.49\u0026ndash;4.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStool disposal of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen disposal/thrown in garbage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.64\u0026ndash;66.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHandwashing practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot regularly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.12\u0026ndash;5.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge of complications of cholera\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNothing happens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u0026ndash;8.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.24\u0026ndash;6.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge on prevention of cholera\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.23\u0026ndash;6.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Information on preventive and control measures from literature review\u003c/h2\u003e \u003cp\u003eThe unmatched case-control study conducted to describe the outbreak, determine its source and risk factors and institute control measures to guide effective prevention and containment strategies provided the intervention including community education, personal hygiene and sanitation programs were emphasized as public health intervention (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The unmatched case-control study conducted to assess the determinants of cholera outbreak in sub-city of Shaggar, Oromia, Ethiopia with 1:2 case to control ratio among 60 cases and 120 controls by using structured questionnaire guided with health education, chlorination of water, strengthening surveillance were implemented. To reduce the risk of future outbreak of cholera, environmental hygiene, practices and the use and accessibility of safe drinking water were interventions to promote at community level (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe active surveillance of cholera outbreak study conducted in town administrative of Guraghe zone of Ethiopia to assess the cholera outbreak, its challenges, and the way forward on public health intervention to solve the knowledge and health services delivery gap related to cholera control concluded that to control cholera outbreak oral cholera vaccination, long-term intervention i.e. WASH measures to ensure safe water and good hygiene practices, early diagnosis and treatment were regarded as the effective measures to prevent and control the disease outbreak (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA retrospective epidemiological study was conducted among 1997 cholera cases to analyze the 2023 cholera outbreak in Sudan and to recommend prevention and control measures in Gadarif State, Sudan concluded that the need of laboratory and epidemiologic surveillance and educational activities to address myths and misconception among community people were the major interventions recommended (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe unmatched case-control study conducted among the person aged more than 5 years with acute watery diarrhea in Gomai community with a total of 43 cases and 68 controls suggested that controlling cholera outbreaks requires strong surveillance and rapid response system. For sustainable control, a broader economic development on universal access to safe drinking water and proper sanitation and waste management were recommended. Alongside, oral cholera vaccines were recommended for effective preventive measures (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). From the most selected literature, the study has pointed out few effective preventive measures based on the priority:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStrengthening surveillance and rapid response\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEnsuring WASH practices\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEnhancing community education and behavioral change\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInitiating oral cholera vaccination\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStrengthening early diagnosis and treatment\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4 DISCUSSION","content":"\u003cp\u003eThe findings of the study provide insight into the dynamics of cholera outbreaks, showing how demographic, environmental, behavioral and knowledge-related factors interact to shape vulnerability. Although the overall attack rate was relatively low 0.74% and no fatalities were recorded, the clustering of cases in wards 11\u0026ndash;14, with ward 13 reported the highest burden. Such disproportionate patterns in the burden of disease recall the need for surveillance system that can detect and respond rapidly at the community level. The fatality rates varied across different studies; Torokaa et al (2025) observed 3.5%, Berhe and EI Bushra (2024) reported 2.6% and Asantewaa\u0026rsquo;s meta-analysis found a pooled rate of 1.3% across low-middle income countries. These differences reflect variations in outbreak severity, health system capacity and timeliness of interventions.\u003c/p\u003e \u003cp\u003eIn the study, participants aged 5\u0026ndash;49 years were nearly three times more likely to have increased risk of cholera compared to older adults. This finding resonates with Torokaa at al. (2025), who reported that individuals below 25 years had over 4 times higher odds of cholera. Younger populations are often more exposed to school environments, dietary habits and ignorance on hygiene maintenance. The gender did not show any association in the study however, Torokaa found more than half of cases were female, suggesting that gender roles in food preparation, water collection and caregiving may contribute to exposure. Ethnicity and education were the social determinants in the study. The finding revealed that cholera is not just a waterborne disease but also associated with social factors.\u003c/p\u003e \u003cp\u003eThe dietary and water-related practices were equally contributing to the increased risk of cholera. Street food consumption was strongly associated with cholera in the study. The participants who consumed food outside the home were 11 times higher at the risk of cholera. Raw food consumption including raw vegetables and meat also increased risk significantly. These findings align with the Torokaa and Mideska (2024), who identified eating outside the home and poor sanitation in food establishments as major contributors. The participants, depending on public taps and untreated water along with cross connections in water supply, were critical hazards in the study. Similar challenges were reported by Mideska in Ethiopia, where safe water sources and poor latrine conditions increased risk and by Berhe et al. (2024), who highlighted inaccessible safe water and low latrine coverage as persistent barriers.\u003c/p\u003e \u003cp\u003eSanitation and hygiene practices further shaped outcomes. Improper disposal of children\u0026rsquo;s\u0026rsquo; stool was associated with an almost 17 times higher odds of risk of cholera than those who rinsed into toilet, while irregular handwashing doubled the odds of cholera. Although latrine availability itself was not significant, the type of latrine mattered with open defecation exclusively reported among the cases. These findings were like Berhe et al who emphasized the need for improved latrine coverage and utilization.\u003c/p\u003e \u003cp\u003eThe gaps in knowledge played a critical role in increasing the risk of cholera. Many cases of the study were unable to recognize complications of cholera and lacked preventive measures and significance of prompt treatment from health facility. Misconceptions persisted among the participants on the cholera transmission as God/insect/fish. Like the study, Bushra et al (2024) found that myths about the water chlorination hindered outbreak control in Sudan.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations of the study\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDespite visible cross connections in the water supply, researchers were not permitted to collect or conduct clinical water tests which prevented confirmation of \u003cem\u003eV. cholerae\u003c/em\u003e contamination and weakened the ability to establish direct environmental factors.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDifferent socioeconomic and age variations in the unmatched case-control study may have influenced the associations. However, the study has gathered information directly from the community people, ensuring the relevant of the data.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"5 CONCLUSION","content":"\u003cp\u003e The unmatched case-control study was conducted among the participants of Birgunj during the cholera outbreak. The major findings of the study identified multiple socio-demographic and behavioral risk factors significantly associated with cholera. The participants aged 5\u0026ndash;49 years, individuals from Muslim ethnic groups and those who were illiterate faced markedly higher odds of risk of cholera. Unsafe food practices and poor water and sanitation behaviors further elevated risk. Lack of awareness about cholera complications and preventive measures also contributed to vulnerability, overall, cholera risk was strongly linked to age, ethnicity, family type, food and water hygiene, sanitation practices and knowledge gaps.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCDC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Centers for Disease Prevention and Control\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Confidence Interval\u003c/p\u003e\n\u003cp\u003eEDCD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Epidemiological Disease Control Department\u003c/p\u003e\n\u003cp\u003eFCHV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Female Community Health Volunteers\u003c/p\u003e\n\u003cp\u003eHDU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;High Dependency Unit\u003c/p\u003e\n\u003cp\u003eIBM SPSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eICU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Odds Ratio\u003c/p\u003e\n\u003cp\u003eORS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Oral Rehydration Salt\u003c/p\u003e\n\u003cp\u003eU.S.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United States\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWASH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Water, Sanitation and Hygiene\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthical approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from Institutional Review Committee (IRC) of Pokhara University and an approval letter from the public health office was obtained before data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe written and verbal consent was taken, and confidentiality was ensured by each participant in the study. If the participant was below 18 years of age, the written consent from their guardian or caretaker was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNo fundings were provided.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; Contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDPP supervised entire study and guided the team throughout the study. NS supported by carefully validating the data and guiding the analysis. The authors (DCT, JK, PP, RS, SS) have equally contributed to the study from the time of proposal development, tool design and translation, data collection and analysis and preparing the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgments\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe show our gratitude to Mr. Raju Sah, Health Coordinator/ Head of Health Division, Birgunj metropolitan city and other staff who provided access to data and helped us during the fieldwork to help identify households. Their cooperation made the challenging parts of this study much smoother. We are grateful to each person who contributed their time and efforts. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZheng Q, Luquero FJ, Ciglenecki I, Wamala JF, Abubakar A, Welo P, et al. Cholera outbreaks in sub-Saharan Africa during 2010\u0026ndash;2019: a descriptive analysis. Int J Infect Dis. 2022 Sept;122:215\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCDC. Cholera global snapshot [Internet]. U.S. Centers for Disease Control and Prevention; 2025 [cited 2025 Aug 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/cholera/about/global-epidemiology-of-cholera.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/cholera/about/global-epidemiology-of-cholera.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICD. Cholera global and southern Africa update. (April 2025) [Internet]. National Institute for comunicable diseases; 2025 [cited 2025 Aug 28]. 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The Kathmandu Post [Internet]. 2025; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://kathmandupost.com/health/2025/08/25/birgunj-cholera-outbreak-largest-since-jajarkot-in-2009\u003c/span\u003e\u003cspan address=\"https://kathmandupost.com/health/2025/08/25/birgunj-cholera-outbreak-largest-since-jajarkot-in-2009\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEDCD. Situation update on cholera outbreak [Internet]. Ministry of Health and Population; 2025 [cited 2025 Aug 28]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchsquare.com/article/rs-4483047/v1\u003c/span\u003e\u003cspan address=\"https://www.researchsquare.com/article/rs-4483047/v1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerhe TM, Fikadu Y, Sahle T, Hailegebireal AH, Eanga S, Ketema T, et al. Existence of cholera outbreak, challenges, and way forward on public health interventions to control cholera outbreak in Guraghe Zones, southern Ethiopia, 2023. Front Public Health. 2024;12:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDan-Nwafor CC, Ogbonna U, Onyiah P, Gidado S, Adebobola B, Nguku P, et al. A cholera outbreak in a rural north central Nigerian community: an unmatched case-control study. BMC Public Health. 2019;19(1):112.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cholera, Acute watery diarrhea, Outbreak Investigation, Unmatched Case-Control Study","lastPublishedDoi":"10.21203/rs.3.rs-8386341/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8386341/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCholera remains a persistent global health threat. Although it is preventable and treatable, it has disproportionality affected vulnerable population lacking water and sanitation particularly among the low-middle income countries. The recent cholera outbreak was seen in Birgunj metropolitan city, Madhesh province, eastern part of Nepal in August 2025. Out of one thousand one hundred fourteen, hundreds of hospitalized within days, exposed critical gaps in water safety, sanitation and community awareness. The study aims to investigate cholera outbreak.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe population-based unmatched case-control study with 1:1 ratio, 63 confirmed cholera cases and 63 community controls from the most affected wards of Birgunj were enrolled in the study. Data was collected though face-to-face interviews using a structured questionnaire on WHO guidelines, alongside secondary outbreak records. Statistical analysis with SPSS included descriptive measures, chi-square tests and binary logistic regression to identify significant risk factors for cholera.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study revealed that limited awareness about cholera complications (OR: 2.30, 95% CI: 0.64\u0026ndash;8.28) and preventive measures (OR: 2.87, 95% CI: 1.23\u0026ndash;6.73) significantly increased the risk of cholera among the participants. The cholera risk was strongly shaped by socio-demographic and behavioral factors. The participants aged 5\u0026ndash;49 years (OR: 2.81, 95% CI: 1.45\u0026ndash;6.92), individuals from Muslim ethnic groups (OR: 12.26, 95% CI: 4.98\u0026ndash;30.14), and those without formal education (OR: 8.85, 95% CI: 2.57\u0026ndash;30.46) were disproportionately affected. Household and community practices such as consuming street food (OR: 11.47, 95% CI: 4.86\u0026ndash;27.07), relying on untreated public tap water (OR: 19.77, 95% CI: 4.40-88.76), unsafe stool disposal (OR: 17.95, 95% CI: 4.64\u0026ndash;66.61), cross-connections (OR: 2.461, 95% CI: 1.49\u0026ndash;4.04) significantly increased risk of cholera. The effective preventive measures improving sanitation and hygiene practices, strengthening community awareness through education and behavioral change and long-term measures like oral cholera vaccination, regular water chlorination and active surveillance.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCholera in Birgunj was influenced by social, behavioral and environmental factors, indicating the urgent need for stronger community awareness and behavioral change, safe water and sanitation practices.\u003c/p\u003e","manuscriptTitle":"Outbreak investigation of cholera in Birgunj, Nepal: An unmatched case-control study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:10:07","doi":"10.21203/rs.3.rs-8386341/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d1703a31-ae8c-4c49-84cb-91413ef8849e","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T06:25:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 10:10:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8386341","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8386341","identity":"rs-8386341","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}