
==== Front
Ann Med Surg (Lond)
Ann Med Surg (Lond)
MS9
Annals of Medicine and Surgery
2049-0801
Lippincott Williams & Wilkins Hagerstown, MD

10.1097/MS9.0000000000000251
00044
3
Correspondence
The outbreak of shigellosis in Sweden as a looming concern for public health: a correspondence
Kaur Navneet MBBS anavneetkkaur1993@gmail.com

Satapathy Prakasini PhD prakasini.satapathy@gmail.com
b
http://orcid.org/0000-0002-6181-6164
Neyazi Ahmad MD dahmadniazi000@gmail.com

http://orcid.org/0000-0002-2828-2375
Padhi Bijaya K. PhD cbkpadhi@gmail.com

a Department of Geography, Jamia Millia Islamia, New Delhi
Departments of b Virology
c Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
d Afghanistan Center for Epidemiological Studies, Herat, Afghanistan
* Corresponding author. Address: Afghanistan Center for Epidemiological Studies, Herat, 3001, Afghanistan. Tel./Fax: 0093790617023. E-mail address: ahmadniazi000@gmail.com (A. Neyazi).
3 2023
17 2 2023
85 3 559560
4 1 2023
8 1 2023
Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.
2023
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/

SDCT
OPEN-ACCESSTRUE
==== Body
pmc Dear Editor,

Since the middle of November, an increasing number of cases of Shigella infection with a travel connection to Cape Verde have been reported in Sweden. On 22 December 2022, the Swedish Public Health Agency, Folkhalsomyndigheten, reported 30 cases of shigellosis with a travel connection to Cape Verde that had been reported in Sweden since mid-November. So far, 11 bacterial isolates have been identified: nine Shigella sonnei and two Shigella boydii 1. European countries such as the Netherlands, Denmark, France, Germany, Portugal, and the United Kingdom have reported cases of Shigella infection associated with Cape Verde travel histories2. Several countries have taken notice of the spread of infection in Cape Verde and informed the European Centre for Disease Prevention and Control and WHO. Infections with various intestinal pathogens, such as Enterohemorrhagic Escherichia coli, Campylobacter, Cryptosporidium, and Giardia, have also been reported among Swedish travelers. Shigella infection associated with travel to Cape Verde has been a persistent issue. This, along with the presence of various species of Shigella and intestinal infections, suggests contamination by food.

Shigella bacteria are extremely virulent enteric pathogens that inflict shigellosis, an intestinal infection. The most prominent mode of transmission of Shigella spp. is fecal-to-mouth contact, which is transmitted from person to person. The main transmission occurs through contaminated food and water. An infected person may experience stomach pain, fever, blood and mucus, and dysentery3.

Shigella is classified into 43 serotypes and four species or subgroups (A, B, C, and D). Historically, subgroup A is designated as Shigella dysenteriae, subgroup B as Shigella flexneri, subgroup C as S. boydii, and subgroup D as S. sonnei 4. Although infections occur worldwide and among people of all ages, prevalent infections are among 1–4-year-olds in low- and middle-income settings. and infected by S. flexneri and S. sonnei account for most of the infection burden. In the 1970s, a distinct epidemiological niche for Shigella became a sexually transmitted disease among men who have sexual relations with other men (MSM). In 2009, uncommon serotypes (S. flexneri 3a) emerged in England and Wales in the MSM community and expanded across continents among the MSM community to low-risk regions of shigellosis4. S. sonnei causes travel-associated shigellosis in high-income countries among people who have visited places with a high prevalence of endemic diseases and a periodic upsurge caused by S. flexneri. The WHO reports that there are at least 80 million cases of shigellosis per year, with about 700 000 deaths5.

Shigellosis contracted during travel can result in the transmission of antimicrobial-resistant Shigella to new population groups. The potential for long-term disability from postinfection complexities such as irritable bowel syndrome and reactive arthritis, in addition to the potential of outbreaks in tourist groups and military deployments. During the 18th and 19th centuries, Shigella infection was a prevalent and severe disease in Sweden. According to the Annual Report (1998), there were 7078 cases of Shigellosis found in Sweden between 1989 and 19986. Approximately 200–400 cases are reported annually in Sweden, most of which were infected overseas, such as in Turkey, India, and Egypt. S. sonnei is the most prevalent species in Sweden now. The number of cases of Shigella infection reported in 2008, 2009, and 2015 was 157, 50, and 43, respectively.

In poor hygiene settings, it is very uncommon for infections to spread directly from person to person, and secondary cases are quite common during outbreaks in Sweden. Typically, the shedding period is less than 4 weeks, but substantially longer carriers are possible. Due to the low infectious dose, around 10–100 bacteria are sufficient to cause disease. When bacteria are in the feces through culture, a diagnosis can be determined. The approach is unreliable since bacteria are quickly killed during sample transfer7. The cases of S. sonnei associated with hotel stays in Cape Verde have so far been confined to European travelers. Consequently, concerns have been raised about the hygiene and sanitation standards of hotels in Cape Verde8.

There is no vaccination present. Due to the low infectious dose, the infection can quickly spread from person to person, making strict hygiene imperative. The food industry should be especially aware of the potential for Shigella infection. Antibiotics are frequently prescribed both to reduce the symptoms of the disease and to prevent its spread. Along with other hygiene practices, regularly washing of hands with soap and running water can help prevent infection9.

Livsmedelsverket, the Swedish food agency, advises travelers traveling abroad, as many countries have higher incidences of disease-causing bacteria and parasites in contaminated food10. Shigella is a significant cause of worldwide morbidity and mortality, impacting young children in places with few resources disproportionately. An insignificant infectious inoculum and lapses in hygiene and sanitation enable Shigella to evade control measures, and the global expansion of strains resistant to current first-line treatments impedes treatment success. The global spread of Shigella strains that are resistant to multiple drugs has been fueled by international travel, and since some Shiga toxin-producing strains could be very dangerous, the world desperately needs to be on guard shield4.

Ethical approval

NA.

Consent

NA.

Sources of funding

None.

Author contribution

All authors are equally contributed.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

None

Guarantor

Ahmad Neyazi.

Provenance and peer review

Not commissioned, externally peer reviewed.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.annalsjournal.com

Published online 17 February 2023
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References

1 Folkhalsomyndigheten Shigella infection (Cape Verde, International November 2022-), 22-12-2-2022. Accessed 1 January 2023. https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/shigellainfektion-internationellt-november-2022-/
2 European Centre for Disease Prevention and Control. Communicable Disease Threat Report, Week 45, 6–12 November 2022. Accessed 1 January 2023. https://www.ecdc.europa.eu/sites/default/files/documents/Communicable-disease-threats-report-Week-45-public.pdf
3 Foster T . Staphylococcus Medical Microbiology, 4th ed. University of Texas Medical Branch at Galveston; 1996.
4 Kotloff KL Riddle MS Platts-Mills JA . Shigellosis. Lancet 2018;391 :801–12.29254859
5 WHO. Extensively Drug-resistant Shigella sonnei infection – Europe-European Region (EURO). Accessed 24 March 2022. https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON364
6 Infection Protection Institute. Infectious Diseases in Sweden 1998, Annual Reports of the Epidemiology Unit. Accessed 1 January 2023. https://www.folkhalsomyndigheten.se/contentassets/0452e7caee4646b5b2f9a66121350571/epidemiologisk-arsrapport-1998.pdf
7 Folkhalsomyndigheten. Disease information about shigella infection. Infectious diseases. Accessed 1 January 2023. https://www.folkhalsomyndigheten.se/smittskydd-beredskap/smittsamma-sjukdomar/shigellainfektion-/
8 EU/Schengen. EU & UK reports Shigella Infection Cases liked to Recent Travel to Cape Verde, Schengenvisa News. Accessed 1 January 2023. https://www.schengenvisainfo.com/news/eu-uk-report-shigella-infection-cases-linked-to-recent-travel-to-cape-verde/
9 Centres for Disease Control and Prevention. Shigella Prevention and Control Toolkit. Accessed 1 January 2023. https://www.cdc.gov/shigella/shigella-toolkit.html
10 Advice for Traveling Abroad. Livemedelsverket. Accessed 1 January 2023. https://www.livsmedelsverket.se/matvanor-halsa--miljo/sjukdomar-allergier-och-halsa/matforgiftning/rad-vid-utlandsresa
