Background: Event-based surveillance (EBS) is an essential component of Early Warning Alert and Response (EWAR) as per the International Health Regulations (IHR), 2005. EBS was established in Sudan in 2016 as a complementary system for Indicator-based surveillance (IBS). This review will provide an overview of the current EBS structure, functions and performance in Sudan and identify the gaps and ways forward. Methods: The review followed the WHO/EMRO guidelines and tools. Structured discussions, observation and review of records and guidelines were done at national and state levels. Community volunteers were interviewed through phone calls. Directors of Health Emergency and Epidemic Control, surveillance officers and focal persons for EBS at the state level were also interviewed. SPSS software was used to perform descriptive statistical analysis for quantitative data, while qualitative data was analysed manually using thematic analysis, paying particular attention to the health system level allowing for an exploration of how and why experiences differ across levels. Written and verbal consents were obtained from all participants as appropriate. Results: Sudan has a functioning EBS; however, there is an underestimation of its contribution and importance at the national and states levels. The link between the national level and states is ad hoc or is driven by the need for reports. While community event-based surveillance (CEBS) is functioning, EBS from health facilities and from non-health sectors is not currently active. The integration of EBS into overall surveillance was not addressed, and the pathway from detection to action is not clear. The use of electronic databases and platforms is generally limited. Factors that would improve performance include training, presence of a trained focal person at state level, and regular follow-up from the national level. Factors such as staff turnover, income in relation to expenses and not having a high academic qualification (Diploma or MSc) were noticed as inhibiting factors. Conclusion: The review recommended revisiting the surveillance structure at national and state levels to put EBS as an essential component and to update guidelines and standard operation procedures SOPs to foster the integration between EBS components and the overall surveillance system. The need for strengthening the link with states, capacity building and re-addressing the training modalities was highlighted.

Cholera is an acute, severe, illness caused by infection with Vibrio cholerae. Cholera outbreaks are closely linked to armed conflicts and humanitarian emergencies. This study describes the cholera outbreak amidst conflict in Gadaref state, discusses the possible factors mediated its spread and proposes future improvements in preparedness and response measures. A retrospective analytical study was conducted using national surveillance records of cholera cases, supported by interviews with key informants involved in preparedness and response, along with a review of state reports, to identify possible factors contributing to the spread and to evaluate the response. The outbreak was confirmed after the isolation of Vibrio cholerae of O1 serotype, with both Inaba and Ogawa serogroups. A total of 2,047 cholera cases records reviewed. The mean age was 16.8 (SD, 15.8) with an equal gender distribution. The case fatality ratio was 2.4% and the overall attack (AR) rate was 7.38 cases per 10,000 population, with the highest in Medeinat Gadaref locality (21.07/10,000). Interviews and reports review suggest that the outbreak was likely imported to villages near Ethiopian border before spreading to other parts of Gadaref. Atbara seasonal river, was the identified source of infection at the beginning. A disrupted health system due to conflict, delays in response teams’ deployment, and late implementation of control measures were identified as factors contributing to response delay and expansion of the outbreak. Oral cholera vaccine campaign was implemented in five localities, followed by an observable decline in cases. Cholera remains a recurrent risk that has been further exacerbated by the armed conflict. The reporting of index cases from a border village highlights the need to strengthen surveillance at points of entry. Investment in case management and risk communication is necessary to improve clinical outcomes. The use of Oral Cholera Vaccine was associated with a decline in cases; however, further field studies are recommended to analyze its actual contribution in limiting the outbreak. The government’s primary role in leading and financing preparedness and response interventions has been limited by the conflict, urging investment in community-led interventions, while moving to more strategic outbreak preparedness and response financing mechanisms remains a priority, with partner support being essential in conflict settings.

In 2023, Sudan experienced a major cholera outbreak affecting 10 states amidst armed conflict that severely disrupted health services. This study aimed to describe the magnitude and pattern of the cholera outbreak in Sudan amidst the armed conflict and provide timely insights. This was a retrospective record-based descriptive (cross-sectional) study. The study used surveillance data available at the national level (from August 2023 - February 2024). Epidemiological measurements were calculated, and data were analysed using Epi Info 7 software. A total of 9,581 cases were reported in 10 states (with an overall attack rate (AR) of 3.5/10,000 people) and 238 reported deaths (with a crude case fatality ratio (CFR) of 2.48%). There was an observable variation in AR and CFR between the states. The duration of the outbreak varied across states, ranging from 4 to 18 weeks. Cholera caused significant mortality and morbidity, facilitated by conflict. To better address recurrent cholera and the challenges imposed by conflict, health authorities need to invest in communities through strengthening engagement, rising awareness and adopting community-based preparedness and response strategies. In addition, ensuring the readiness of the primary healthcare level requires training for healthcare workers and maintaining the flow of supplies.

Background: Sudan has a long history of struggling with recurrent cholera outbreaks. The interplay of infrastructure damage, massive displacement, and limited access to safe water and sanitation has increased the risk of cholera transmission. The study aims to identify priority areas for multisectoral interventions (PAMIs) to inform public health policy and ensure evidence-based strategic control of cholera in Sudan. Methods: In this retrospective study, national cholera data from 2016 to 2024 (excluding 2020–2022) were used. The Global Task Force on Cholera Control (GTFCC) tool for identifying PAMIs was applied to the analysis. Key epidemiological indicators, such as incidence, mortality, and persistence of cholera, were used to score each geographical unit and were subsequently summed to generate a priority index (PI). Furthermore, vulnerability factors were evaluated, including water, sanitation, and hygiene (WASH) infrastructure, crowded settings, displacement, inaccessibility, and community awareness. A national stakeholder validation workshop reviewed and contextualized the findings to finalize the list of PAMIs. This study also documents the immediate applications of PAMIs for strategic cholera control. Results: A priority index threshold of 6 was established through stakeholders’ consensus, which resulted in the identification of 52 PAMIs. These administrative units account for 80% of reported cholera cases and 77% of deaths, encompassing 31.5% of Sudan’s total population. The identified PAMIs were immediately applied to guide preventive oral cholera vaccine (OCV) planning, resulting in the selection of 40 high-risk localities and the development of Sudan’s first national 3-year OCV plan. In addition, they informed the development of the updated National Cholera Plan (NCP; 2025–2030) as a long-term strategy for cholera control. Conclusion: The study provides strong evidence-based identification of PAMIs in Sudan and supports local, national, regional, and global efforts to control cholera risk. Targeted interventions in these areas are essential to contain outbreaks and build resilient public health systems. The PAMIs identification exercise informed evidence-based prioritization and planning for preventive OCV deployment and catalyzed the establishment of a national committee that developed the updated national cholera plan (2025–2030), reflecting the country’s shift toward proactive and sustainable cholera prevention. Sudan’s experience demonstrates the feasibility and policy relevance of the PAMIs framework, even in highly fragile humanitarian settings.

Introduction: The ongoing conflict in Sudan has intensified the country’s already fragile public health landscape. Since July 2024, Sudan has faced one of the most extensive cholera outbreaks in its modern history, affecting 17 states and 109 localities and resulting in 83,245 reported cases and 2,124 deaths by June 2025. Traditional, hierarchical outbreak response systems have proven insufficient in such a dynamic, volatile environment. Methods: Using Sudan’s 2024–2025 cholera outbreak as a case study, this paper proposes the Orchestrated Symphony Model , an innovative framework that integrates systems thinking and orchestration governance, to design a model for outbreak management in fragile and conflict-affected settings. Results: The model conceptualizes the Ministry of Health as a conductor leading an orchestra of diverse stakeholders. Each stakeholder represents an instrument section whose coordinated actions create a harmonized and adaptive response. Grounded in systems thinking theory, particularly the Iceberg and Biomatrix models, this framework identifies leverage points for governance, coordination, and resource optimization. Conclusion: The Orchestrated Symphony Model is proposed as a policy reform and practice improvement framework for cholera outbreak response generally and in conflict-affected settings particularly.