A 37-year-old man from Bara district who was infected with diarrheal disease, died on Saturday, while receiving treatment at Narayani Hospital in Birgunj. With this, the number of people dying from diarrheal infection since the outbreak of cholera in Birgunj Metropolitan City some 10 days ago has reached four.

“The patient died yesterday,” said Dr Chuman Lal Das, director at the hospital. “The patient had an acute kidney injury and an intestinal infection.”

Cholera is a highly infectious disease that causes severe diarrhoea and vomiting, which can lead to dehydration and death within a few hours if left untreated. The National Public Health Laboratory has confirmed that Vibrio cholerae o1 Ogawa serotype is responsible for the outbreak.

According to the Health Office, Parsa, 821 people from various wards of the metropolis and nearby local units and districts had been hospitalised with diarrheal infections as of 10 am on Sunday.

Thirty-one newly infected patients sought treatment on Sunday morning. On Saturday, 90 infected people were hospitalised. The Health Office said that 17 seriously ill patients have been receiving intensive care, and six have been admitted to the high-dependency unit.

Health workers serving in the disease-hit areas complain of exhaustion due to continuous deployment.

“We have been exhausted due to continuous work,” said Das. “Healthworkers, including doctors, have complained of burnout.”

The health workers said that the spread of the infection has slowed but not stopped.

The metropolis has extended the shutdown of academic institutions until Tuesday.

Public health experts say the ongoing Birgunj outbreak is the largest since the Jajarkot incident in 2009. Sixteen years ago, the far-western district of Jajarkot saw a major cholera outbreak that killed several and infected hundreds.

Experts say that the outbreak of cholera exposes critical gaps in the government’s preparedness and response system, and water and sanitation conditions.

Experts are particularly alarmed by both the severity of the outbreak and the deaths it has caused.

Nepal often witnesses outbreaks of water- and food-borne diseases, including cholera, during the monsoon season as floodwaters contaminate most of the drinking water sources.

Last year, at least 95 cholera cases were confirmed in Kathmandu, Lalitpur, Jajarkot, Pyuthan, Makawanpur, Rolpa, Sindhupalchok, Achham, and Rautahat districts.

Experts say poor sanitation and hygiene make the country remains highly vulnerable to waterborne diseases, including diarrhoea, dysentery, typhoid, hepatitis, and cholera, especially in the monsoon season.

They say the risk of waterborne diseases will not decrease until the country’s water and sanitation conditions improve, and people get safe drinking water. Several other factors, including storage conditions, supply pipes, and pollution of water sources, also impact the quality of water supplied to households.

“Awareness drives and health education play a vital role in containing the outbreak, and the general public must be informed about what is happening in their surroundings and what precautionary measures to take,” said Dr Baburam Marasini, former director at the Epidemiology and Disease Control Division. “Authorities must invest in improving water and sanitation conditions.”

The World Health Organisation says cholera is a global threat to public health, and a multifaceted approach is key to controlling the disease and reducing deaths.

Meanwhile, officials at the Family Welfare Division under the Department of Health Services said they have been exploring the possibility of a vaccine against cholera to contain the spread.

“We have discussed this with the representatives from the Global Alliance for Vaccines and Immunisation,” said Dr Bibek Kumar Lal, division director. “A proposal for a vaccine has not been prepared yet. We must improve water and sanitation conditions and strengthen our health system to be eligible for the vaccine.”

The Health Ministry administered cholera vaccines to people from affected areas of Kapilvastu, Rautahat, and Kathmandu a few years ago.