LAUSR

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 midNovember. So far, 11 bacterial isolates have been identified: nine Shigella sonnei and two Shigella boydii. 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 histories. 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 dysentery. 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. Although infections occur worldwide and among people of all ages, prevalent infections are among 1–4-year-olds in lowand 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 andWales in theMSM community and expanded across continents among the MSM community to low-risk regions of shigellosis. S. sonnei causes travel-associated shigellosis in highincome 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 deaths. 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 1998. 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 themost 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 transfer. 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 Verde. 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 infection. aDepartment of Geography, Jamia Millia Islamia, New Delhi, Departments of bVirology, cCommunity Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India and dAfghanistan Center for Epidemiological Studies, Herat, Afghanistan