In transition: current health challenges and priorities in Sudan

5,10-methylenetetrahydrofolate reductase C677T gene polymorphism as a risk factor for premature coronary artery disease in patients with type 2 diabetes mellitus

Background

Africa, like the rest of the world, is experiencing an increasing prevalence of diabetes mellitus. Diabetes increases the risk for coronary artery disease (CAD) by fourfold compared to people without diabetes. C677T polymorphism in methylenetetrahydrofolate reductase (MTHFR) and hyperhomocysteinemia were reported by many studies as risk factors for CAD among patients with type 2 diabetes mellitus (T2DM). Early detection of modifiable risk factors for CAD is an important aspect of management of diabetes. This is the only study in Sudan which investigates the association between MTHFR genotypes and plasma homocysteine levels, and their role in premature CAD (PCAD) among patients with T2DM.

Methods

This study is a comparative study. We enrolled 226 Sudanese patients with T2DM, age range 25-60 years, recruited from Alshaab and Omdurman teaching hospitals in Khartoum State. 113 patients had CAD confirmed by angiography and electrocardiography (ECG) and 113 had no evidence of CAD. Polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP), using Hinf1 restriction enzyme, were used to determine MTHFR genotypes. Plasma homocysteine levels were determined by enzymatic assay on the Hitachi Cobas Integra® 400 plus. Data was analyzed using statistical package for Social Sciences (SPSS) 23, using Mann-Whtney U test, general linear model, Chi-square test and logistic regression analysis.

Results

The frequencies of TT, CT, and CC genotypes were 16,40 and 44% among T2DM patients with PCAD. In T2DM patients without PCAD, the frequencies of TT, CT, and CC genotypes were 00,19 and 83%. The T allele showed strong association with PCAD among T2DM patients, p <0.001, odds ratio (OR) 6.2, 95% CI (3.4-11.6). Patients with PCAD showed higher plasma homocysteine levels than patients without PCAD (13.5 µmol/L versus 10 µmol/L, p < 0.001). The T allele had significant effect on homocysteine level, (p <0.001). Plasma homocysteine levels were higher in individuals with TT genotype than those with CT or CC genotypes in patients with PCAD (16.2 + 5.3, 14.3 + 5.7 and 12.9 + 5.02 µmol/L, p=0.017). Homocysteine levels showed a significant association with CAD, p<0.001, OR 3.2, 95% CI (1.9-5.5).

Conclusions

Our study suggests that C677T polymorphism of MTHFR gene and hyperhomocysteinemia are risk factors for PCAD in Sudanese population with T2DM.

Extensive genetic diversity in Plasmodium vivax from Sudan and its genetic relationships with other geographical isolates

Plasmodium vivax, traditionally overlooked has experienced a notable increase in cases in East Africa. This study investigated the geographical origin and genetic diversity of P. vivax in Sudan using 14 microsatellite markers. A total of 113 clinical P. vivax samples were collected from two different ecogeographical zones, New Halfa and Khartoum, in Sudan. Additionally, 841 geographical samples from the database were incorporated for a global genetic analysis to discern genetic relationships among P. vivax isolates on regional and worldwide scales. On the regional scale, our findings revealed 91 unique and 8 shared haplotypes among the Sudan samples, showcasing a remarkable genetic diversity compared to other geographical isolates and supporting the hypothesis that P. vivax originated from Africa. On a global scale, distinct genetic clustering of P. vivax isolates from Africa, South America, and Asia (including Papua New Guinea and Solomon Island) was observed, with limited admixture among the three clusters. Principal component analysis emphasized the substantial contribution of African isolates to the observed global genetic variation. The Sudanese populations displayed extensive genetic diversity, marked by significant multi-locus linkage disequilibrium, suggesting an ancestral source of P. vivax variation globally and frequent recombination among the isolates. Notably, the East African P. vivax exhibited similarity with some Asian isolates, indicating potential recent introductions. Overall, our results underscore the effectiveness of utilizing microsatellite markers for implementing robust control measures, given their ability to capture extensive genetic diversity and linkage disequilibrium patterns.

The Needs of Patients With Chronic Disease in Transitional Care From Hospital to Home in Sudan: A Qualitative Study

The growing burden of chronic non-communicable diseases demands improved post-discharge care. The Sudanese healthcare system faces challenges in providing coordinated care for patients with chronic conditions after hospital discharge. This qualitative study explored the experiences of patients with chronic disease in transitional care from hospital to home to identify improvement targets. Purposive sampling was used to interview 17 participants from different hospitals in Khartoum, Sudan. Audio recordings were transcribed and analyzed using principles of content analysis to identify themes and the relationship between them. Thematic analysis revealed 4 main themes describing the perceived needs of the patients. These were (1) feeling well-informed about post-discharge care goals and plans; (2) feeling cared for during hospital admission and follow-up visits; (3) feeling safe during the transitional care process; and (4) having access to follow-up services. This study highlights the importance of improving hospital patient education through effective communication to facilitate care transitions.

Problems with gestational age estimation by last menstrual period and ultrasound among late antenatal care attendant women in a low-resource setting in Africa, Sudan

INTRODUCTION

Accurate estimation of gestational age is essential to interpret and manage several maternal and perinatal indicators. Last menstrual period (LMP) and ultrasound are the two most common methods used for estimating gestational age. There are few published studies comparing the use of LMP and ultrasound in Sub-Saharan Africa to estimate gestational age and no studies on this topic in Sudan.

MATERIAL AND METHODS

A cross-sectional study was conducted in Gadarif Maternity Hospital in Sudan during November through December 2022. Sociodemographic information was collected, and the date of the first day of each participant's LMP was recorded. Ultrasound examinations were performed (measuring crown-rump length in early pregnancy and biparietal diameter and femur length in late pregnancy) using a 3.5-MHz electronic convex sector probe. Bland-Altman analysis was performed.

RESULTS

Four-hundred seventy-six pregnant women were enrolled. The median (interquartile range [IQR]) age and gravidity was 24.0 (20.0‒29.0) years and 2 (1‒4), respectively. There was a strong positive correlation between gestational age determined by LMP and ultrasound (r = 0.921, P < 0.001). The mean gestational age estimate according to LMP was higher than that determined by ultrasound, with a difference, on average, of 0.01 week (95% confidence interval [CI]: - 0.05, 0.07). Bland-Altman analysis showed the limits of agreement varied from - 1.36 to 1.38 weeks. A linear regression analysis showed proportional bias. The coefficient of difference of the mean was equal to 0.26 (95% CI: 0.01, 0.03, P < 0.001).

CONCLUSION

Based on our results, there was a bias in LMP-based gestational age estimates when compared with the reproducible method (ultrasound).

Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis

Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.

Effectiveness of hospital-to-home transitional care interventions and consultation for implementation in Sudan: a scoping review of systematic reviews

Background

Hospital discharge is often associated with a lack of continuity resulting in fragmented care, particularly in low-income countries. As there is limited information about interventions in these countries and no study evaluating the effectiveness of hospital discharge interventions, we conducted a scoping review to identify effective hospital-to-home transitional care interventions and explore their applicability in a low-income country (Sudan).

Methods

Our scoping review of systematic reviews and meta-analyses classed interventions as effective, ineffective, undesirable, or uncertain, based on the quality of their evidence and their estimated effects on the following outcomes: readmission rates, mortality, costs, quality of life, and adverse outcomes) and certainty of evidence. Our authors from Sudan used the SUPPORT summary tool to determine if three effective interventions could be implemented in Sudan.

Results

Out of 3,276 articles that were identified, and 72 articles were reviewed, 10 articles has been included in the review. Seven interventions were classified as effective, one as ineffective, and none with undesirable effects. Eight interventions were classified as having an uncertain effect. The effective interventions were composed of home visits, information and communication technology (ICT), case manager models, multidisciplinary teams, and self-management support.

Conclusions

The finding of this study suggested that a combining two to four interventions can improve enhance hospital-to-home transitional care. Effective interventions are composed of home visits, ICT, case manager models, multidisciplinary teams, and self-management support. The implementation of these interventions in Sudan was found to be undermined by contextual factors such as inadequate human resources, telecommunication instability, and inequality in accessibility. These interventions could be tailored based on an in-depth understanding of the contextual factors in low-income countries that influence implementation.

Systematic Review Registration

https://osf.io/9eqvr/, doi: 10.17605/OSF.IO/9EQVR.

Undergraduate oncology education in Sudanese public medical schools; a national cross-sectional study

BACKGROUND

Cancer was the fifth leading cause of death in Sudan general hospitals in 2020, and its incidence is increasing. Medical students' cancer education is key in cancer control. Evaluating the current education is the first step in optimizing it. The aim of this study was to assess undergraduate oncology education in Sudan public medical schools as reflected by the graduates of the year 2021-2022.

METHOD

This was a cross-sectional institution-based study. A validated online questionnaire was sent between 8 September and 11 November 2022 to graduates who were selected using a stratified random sampling technique from 17 Sudan public medical schools. The data were collected using Google Forms and analyzed using R software version 4.2.2 and Microsoft Excel 2022.

RESULTS

A total of 707 graduates completed the questionnaire. They reported generally poor exposure to oncology. Palliative and radiation oncology in addition to chemotherapy daycare units were never attended by 76.0%, 72.0%, and 72.0% of graduates, respectively. The massed oncology curriculum was associated with increased hours of lectures dictated to medical (p = 0.005), radiation (p < 0.001), and palliative oncology (0.035). It was associated with an increased likelihood of assessment in breaking bad news (p < 0.001), counseling cancer patients (p = 0.015), and oncology-related knowledge (p < 0.001). The massed curriculum was associated with a decrease in interest in pursuing an oncology career (p = 0.037). Students were generally confident in their oncology competencies, and no difference was observed in relation to the curriculum approach (p > 0.05).

CONCLUSION

This study reflected poor exposure to oncology at the undergraduate level in Sudanese public medical schools. The massed oncology curriculum was associated with formal assessment of oncology-related competencies and better exposure to some disciplines, such as radiation and palliative oncology. Nonetheless, it was associated with decreased interest in an oncology career. In spite of the poor exposure, graduates were confident in their skills in oncology-related competencies. Further objective analysis of competence is needed.

Progress and challenges in implementing non-communicable disease policies in Sudan

Non-communicable diseases (NCD) pose a substantial global public health challenge, representing the leading cause of morbidity and mortality worldwide. This study investigates the progress and challenges in implementing NCD policies in Sudan. Document analysis following the ready your materials, extract data, analyse data and distil your findings (READ) approach, was utilized to review published literature and reports. Data from the NCD Progress Monitor showed that the percentage of NCD-related mortality had increased from 32% in 2015 to 54% in 2022. Sudan's progress in implementing NCD policies has been slow and challenging; eight of the 19 NCD target indicators had never been fully achieved, and only five targets were fully achieved in the year 2022. However, these figures may be underestimated due to the lack of robust NCD information systems. Like many countries, Sudan faces challenges in implementing NCD policies, particularly those targeting healthy diets, medications and data management systems. This may be linked to the prolonged history of conflict, shortage of trained health personnel, limited resources and lack of robust NCD surveillance systems in the country. The ongoing devastating war and destruction of the healthcare system infrastructure in Sudan further intensified these challenges. Prioritizing NCD policies and programmes during the anticipated post-conflict health system reforms is crucial for enhancing NCD prevention and outcomes in Sudan.

Antenatal Care Services in Sudan Before and During the 2023 War: A Review Article

Antenatal care (ANC) is provided by skilled healthcare professionals to pregnant women to ensure the best health conditions for both mother and baby during pregnancy. It includes risk identification, prevention, management of pregnancy-related diseases, health education, and health promotion. Antenatal care has a great effect on vital health indicators such as maternal and neonatal mortality by identifying and treating pregnancy-related complications. Political instability and armed conflict have seriously affected the health system, which has catastrophic implications for pregnant women's health. This review aimed to summarize the literature on ANC in Sudan before and during political instability and war by highlighting its effect on maternal mortality, coverage, care providers, quality of care, accessibility, and utilization. Other aspects of this review are the ANC components and service provision during the war. In addition, the author tried to identify the gaps and point out the future research needs in Sudan. A total of 58 articles about ANC in Sudan have been reviewed through PubMed, Google Scholar, ResearchGate databases, and other search tools. The keywords used were "antenatal care", "coverage", "service providers", "service quality", "accessibility and utilization", "components", and "ANC during the war". All the keywords were followed by "Sudan" to confine the search. According to the reviewed data, ANC services in Sudan, even during normal political situations, were not sufficient and of poor quality in most of the reviewed regions. The political instability and armed conflicts worsened the situation, and it became catastrophic. To improve the accessibility and quality of ANC services, we will need the collaboration of all stakeholders to address the health needs of vulnerable groups, people in remote rural areas, and nomadic communities towards providing the required health services in general and ANC in particular. On the other hand, an important aspect of this development is the availability of skilled healthcare providers and the adoption, revision, and updating of working procedure guidelines to match the needs of the local communities. The main shareholders are the local communities; they must be empowered and involved by raising their awareness. Then, effective, punctual, and applicable contingency plans should be ready for any unfortunate crises.

Factors associated with completeness in documentation of diagnostic work-up and treatment in patients with breast cancer in Sudan

Purpose

This study evaluates the relationship between geography and ethnicity on the completeness of documentation of diagnostic work-up and treatment modalities in Sudan for patients with breast cancer.

Methods

This retrospective study used data abstracted from patients with breast cancer receiving cancer care at Sudan's largest cancer centre (Radiation and Isotopes Center Khartoum) in 2017. Patient demographic and clinical characteristics were abstracted from paper medical records. Odds ratios and 95% confidence intervals were estimated to evaluate complete diagnostic work-up on ethnic group, origin and residence using binomial logistic regression models.

Results

Of 237 patients, the median age was 52 (interquartile range 43-61). Most often patients identified as Arab (68%), originated from Central, Northeastern and Khartoum regions (all 28%) and lived in the Khartoum region (52%). Overall, 49% had incomplete diagnostic work-up, with modest differences by ethnicity and geography. In adjusted analyses, non-statistical differences were found between the ethnic group, geographic origin and residence and having complete diagnostic work-up. For treatment modality, significant differences were observed between receptor status and receiving hormone therapy (p = 0.004). Only 28% of patients with HR+ breast cancer received hormonal therapy. For those with HR- or undocumented breast cancer subtype, 36% and 17% received hormone therapy, respectively.

Conclusion

Approximately half of Sudanese patients with breast cancer had incomplete diagnostic work-up, irrespective of ethnicity and geography. Moreover, a high proportion of patients received inappropriate treatment. This underlines a considerable systems-based quality gap in care delivery, demanding efforts to improve diagnostic work-up for all patients with breast cancer in Sudan.

Prevalence of Metabolic Syndrome among Early Adolescents in Khartoum State, Sudan

BACKGROUND

Metabolic syndrome (MetS) is rapidly increasing in prevalence with rising childhood obesity and sedentary lifestyles worldwide. The aim of this study was to estimate the prevalence of MetS and its components among Sudanese early adolescents in Khartoum State.

METHODS

A descriptive cross-sectional study was conducted at primary schools in Khartoum State. A questionnaire was administered to assess the sociodemographic characteristics of the participants. Anthropometric, blood pressure, and biochemical measurements were taken.

RESULTS

In total, 921 students, boys and girls aged 10-15 years old, participated in the study. The mean age of the participants was 12.59 ± 1.21 years. The overall prevalence rate of MetS was 2.3% using International Diabetes Federation (IDF) criteria. MetS was significantly more prevalent among boys than girls (3.4% vs. 1.5%). Obese adolescents had higher MetS prevalence than those who were overweight (14.9 vs. 2.8, p < 0.001).

CONCLUSION

Boys had a significantly higher prevalence of metabolic syndrome than girls. Early adolescents from Sudan who are obese had more risk factors for MetS than those who are normal weight or overweight. It is important to address the causes of increased risk for MetS early in life to prevent the development of the disease in adult life.

Pattern and Trends in Adult Hospitalization/Admission and Mortality Among Medical Ward Inpatients at Gadarif Hospital in Eastern Sudan: A Four-Year Retrospective Study

Purpose

Sub-Saharan Africa suffers from a dual impact of communicable (CDs) and non-communicable diseases (NCDs). There is scarce data on causes, trends of admission, and deaths among patients in Sudan. We aimed to determine the causes, trends of admission, and mortality among adult patients admitted to Gadarif Hospital in Eastern Sudan.

Patients and Methods

The medical records of adult patients admitted to Gadarif medical wards from January 2017 to December 2020 were reviewed for age, gender, causes of admission, and outcomes. Multivariate Cox regression analysis was used to analysis factors (age, sex, years, and disease) associated with the mortality.

Results

Of the 7230 patients who were admitted, 2221 (34.7%) were females and 5009 (69.3%) were males. The median age (interquartile range, IQR) was 47.0 (35.0) years. Of these 7230 patients, 3167 (43.8%) and 4063 (56.2%) patients were admitted with CDs and NCDs, respectively. Cardiovascular diseases (18.4%), snakebites (12.9%), and visceral leishmaniasis (12.0%) were the most common causes of admission. The overall in-patient adult deaths were 674 (9.3%). Cardiovascular diseases (22.3%), neurological diseases (16.9%), sepsis (15.9%), renal diseases (13.9%), and snakebites (8.3%) were the most common causes of inpatient mortality. Malignancy (20.7%), sepsis (20.9%), neurological diseases (17.4%), and cardiovascular diseases (13.8%) comprised the highest case fatality rates among the admitted patients. Using a Cox regression model (adjusted), age (adjusted hazard ratio = 1.02, 95% confidence interval = 1.01‒1.03) was associated with increased mortality hazard. However, the gender and years of admission were not associated with increased mortality hazard.

Conclusion

Admissions and mortality rates for CDs and NCDs are high compared with other African countries. Preventive measures are required to avert the high burden of these diseases. Health care systems in Sudan need to be prepared to deal with the dual burden of the diseases.

Evaluating utility and feasibility of mismatch repair testing of colorectal cancer patients in a low-middle-income country

Molecular pathology services for colorectal cancer (CRC) in Sudan represent a significant unmet clinical need. In a retrospective cohort study involving 50 patients diagnosed with CRC at three major medical settings in Sudan, we aimed to outline the introduction of a molecular genetic service for CRC in Sudan, and to explore the CRC molecular features and their relationship to patient survival and clinicopathological characteristics. Mismatch repair (MMR) and BRAF (V600E) mutation status were determined by immunohistochemistry. A mismatch repair deficient (dMMR) subtype was demonstrated in 16% of cases, and a presumptive Lynch Syndrome (LS) diagnosis was made in up to 14% of patients. dMMR CRC in Sudan is characterized by younger age at diagnosis and a higher incidence of right-sided tumours. We report a high mortality in Sudanese CRC patients, which correlates with advanced disease stage, and MMR status. Routine MMR immunohistochemistry (with sequential BRAF mutation analysis) is a feasible CRC prognostic and predictive molecular biomarker, as well as a screening tool for LS in low-middle-income countries (LMICs).

Association Between the Prevalence of Schistosomiasis in Elementary School Students and Their Parental Occupation in Sudan

Global efforts to identify groups at high risk for schistosomiasis have mainly concentrated on identifying their geographical distribution. Investigations on the socioeconomic characteristics of high-risk groups are relatively scarce. This study aimed to explore the associations between schistosomiasis among students and their parents’ occupations. A nationwide cross-sectional survey was conducted targeting 105,167 students in 1,772 primary schools across Sudan in 2017. From these students, 100,726 urine and 96,634 stool samples were collected to test for Schistosoma haematobium and S. mansoni infection. A multi-level mixed effect analysis was used with age and sex as fixed factors, and school as a random factor. The odd ratios (ORs) of practicing open defecation among farmers’ children were almost 5 times higher than their counterparts whose parents were government officials (OR=4.97, 95% confidence intervals (CIs): 4.57-5.42, P<0.001). The ORs of contacting water bodies for watering livestock among farmers’ children were more than 4 times higher than those of children whose parents were government officials (OR=4.59, 95% CIs: 4.02-5.24, P<0.001). This study shows that schistosomiasis represents a disease of poverty and that farmers’ children constituted a high-risk group.

Distinct Schistosoma mansoni-Specific Immunoglobulin Subclasses Are Induced by Different Schistosoma mansoni Stages-A Tool to Decipher Schistosoma mansoni Infection Stages

Despite the existence of an effective medication against schistosomiasis, the disease remains a major health problem in affected areas, especially for those lacking appropriate sanitary facilities. Moreover, treatment cannot prevent re-infection since it is only effective on adult schistosome worms. Previous retrospective studies in the Sudan have discovered unique immuno-epidemiological profiles in uninfected individuals and those positive for Schistosoma mansoni via polymerase chain reaction (PCR) but egg-negative and those with eggs in their stool. Expanding on these data, serum samples from these individuals were further investigated for the presence of cercarial (SmCTF)-specific antibodies, which would indicate immune responses at the early stages of infection. Indeed, SmCTF IgG1, 2, 3 and 4 levels were significantly elevated in SmPCR⁺ individuals when compared to egg⁺ patients. Following multivariable regression analysis, including SmCTF-specific Igs, Schistosoma egg antigen (SEA)-specific and Schistosoma worm antigen (SWA)-specific immunoglobulins revealed a specific immunoglobulin (Ig) profile of individuals presenting different states of infection, which may be a useful future tool in order to identify egg⁻ individuals and thereby prevent unnecessary treatments.

Unequal geographic distribution of water and sanitation at the household and school level in Sudan

The Sudanese Government launched the National SDG-6 Plan and commences its implementation to achieve and sustain universal and equitable access to basic WASH services by 2030. It is critical to understand the geographical heterogeneity of Sudan and patterns in the inequality of access to safe drinking water and sanitation. Through such research, the disease control strategy can be optimized, and resource allocation can be prioritized. We explored spatial heterogeneity and inequality in access to improved water and sanitation across Sudan by mapping the coverage at both the state and district levels. We decomposed the inequality across Sudan into within-state, between-state, within-district, and between-state inequalities using the Theil L and Theil T indices. We calculated the Gini coefficient to assess the inequality of access to improved water and sanitation, based on the deviation of the Lorenz curve from the line of perfect equality. The study population was 105,167 students aged 8–13 at 1,776 primary schools across the country. Geographical heterogeneity was prominent in the Central Darfur, South Darfur, East Darfur, Kassala, West Kordofan, and Blue Nile States, all of which showed severe inequality in access to an improved latrine at the household level in terms of the Theil T or Theil L index. The overall inequality in the coverage of improved sanitation went beyond the warning limit of 0.4 for the Gini coefficient. The inequality in terms of the Theil L and Theil T indices, as well as the Gini coefficient, was always higher for improved sanitation than for improved water at the household level. Within-state inequality accounted for 66% or more of national inequalities in the distribution of improved sanitation and drinking water for both the Theil L and Theil T indices. This is the first study to measure geographical heterogeneity and inequalities in improved water and sanitation coverage across Sudan. The study may help to prioritize resource allocation to areas with the greatest water and sanitation needs.

Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.

Prevalence of glucose-6-phosphate dehydrogenase deficiency (G6PDd), CareStart qualitative rapid diagnostic test performance, and genetic variants in two malaria-endemic areas in Sudan

Glucose-6-phosphate dehydrogenase deficiency (G6PDd) is the most common enzymopathy globally, and deficient individuals may experience severe hemolysis following treatment with 8-aminoquinolines. With increasing evidence of Plasmodium vivax infections throughout sub-Saharan Africa, there is a pressing need for population-level data at on the prevalence of G6PDd. Such evidence-based data will guide the expansion of primaquine and potentially tafenoquine for radical cure of P. vivax infections. This study aimed to quantify G6PDd prevalence in two geographically distinct areas in Sudan, and evaluating the performance of a qualitative CareStart rapid diagnostic test as a point-of-care test. Blood samples were analyzed from 491 unrelated healthy persons in two malaria-endemic sites in eastern and central Sudan. A pre-structured questionnaire was used which included demographic data, risk factors and treatment history. G6PD levels were measured using spectrophotometry (SPINREACT) and first-generation qualitative CareStart rapid tests. G6PD variants (202 G>A; 376 A>G) were determined by PCR/RFLP, with a subset confirmed by Sanger sequencing. The prevalence of G6PDd by spectrophotometry was 5.5% (27/491; at 30% of adjusted male median, AMM); 27.3% (134/491; at 70% of AMM); and 13.1% (64/490) by qualitative CareStart rapid diagnostic test. The first-generation CareStart rapid diagnostic test had an overall sensitivity of 81.5% (95%CI: 61.9 to 93.7) and negative predictive value of 98.8% (97.3 to 99.6). All persons genotyped across both study sites were wild type for the G6PD G202 variant. For G6PD A376G all participants in New Halfa had wild type AA (100%), while in Khartoum the AA polymorphism was found in 90.7%; AG in 2.5%; and GG in 6.8%. Phenotypic G6PD B was detected in 100% of tested participants in New Halfa while in Khartoum, the phenotypes observed were B (96.2%), A (2.8%), and AB (1%). The African A- phenotype was not detected in this study population. Overall, G6PDd prevalence in Sudan is low-to-moderate but highly heterogeneous. Point-of-care testing with the qualitative CareStart rapid diagnostic test demonstrated moderate performance with moderate sensitivity and specificity but high negative predicative value. The two sites harbored primarily the African B phenotype. A country-wide survey is recommended to understand GP6PD deficiencies more comprehensively in Sudan.

Leishmaniasis Beyond East Africa

Climate change is having a substantial impact on our environment and ecosystems and has altered the way humans live, access, and utilize resources with increased risk of zoonotic infectious disease encounters. As global temperatures continue to increase, they impact on public health, migration, food security and land conflict, and as new environments become favorable, exposure to disease carrying vectors. Increased forests or natural habitat clearance for land repurposing, urbanization, road building, and water management are related to an increase in emerging vector borne parasitic diseases. The East African region remains one of the most impacted regions globally for leishmaniasis, a vector borne disease that impacts significantly on the health, wellbeing and livelihoods of affected communities and for which a lack of reporting and control interventions hinder progress toward elimination of this neglected tropical disease. As our world continues to transform, both politically and climatically, it is essential that measures are put in place to improve surveillance and disease management with implementation of control measures, including vector control, especially in low- and middle-income countries that are expected to be most impacted by changes in climate. Only through effective management, now, can we be sufficiently resilient to preventing the inevitable spread of vectors into suitable habitat and expansion of the geographical range of leishmaniasis. This review offers a current perspective on Leishmaniasis as an endemic disease in East Africa and examines the potential of the recent emergence of Leishmania infection in hitherto unaffected regions to become a public health concern if no disease management is achieved.

Knowledge, attitude and practice of the Sudanese people towards COVID-19: an online survey

Background

The Novel Corona virus SARS-CoV-2 emerged to affect the human population in 2019 causing COVID-19 pandemic. The only preventive measures available are social distancing, hand washing and face masks. This study aims to assess the knowledge, attitude and practice of the Sudanese people towards COVID-19.

Methods

An online cross-sectional study targeting adult Sudanese people was conducted in April 2020. The study used a self-administered questionnaire containing 18 knowledge questions, 5 questions for attitude and six questions for practices. Social media such as Facebook and WhatsApp were utilized to disseminate the questionnaire. The total number of eligible questionnaires available for analysis by the end of the period was 987.

Results

The mean (±SD) age of respondents was 30.13 (±9.84) years with males representing 55.4%. The majority were university and higher education levels (95.2%), residing in Khartoum (71.7%). The mean (±SD) knowledge score of the participants was 15.33 (± 2.24) and was found to be associated with education level and age groups (p-value = 0.022, P value =0.010) respectively. The mean (±SD) attitude score was 04.15 (± 0.97) and was significantly associated with older groups and better-educated participants (p-value =0.001, p-value = 0.048) respectively. The practices related to COVID-19 preventive measures mean (±SD) was 02.58 (± 1.73) with a significant difference between age groups and area of residence.

Conclusions

This study showed that the participants had good knowledge and satisfactory attitude that was not similarly expressed into practice. Efforts are needed in health education and law enforcement to improve the practices among all groups with special emphasis on younger and less educated males.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10319-5.

The first laboratory-confirmed imported infections of SARS-CoV-2 in Sudan

BACKGROUND

The rapidly growing pandemic of coronavirus disease 2019 (COVID-19) has challenged health systems globally. Here we report the first identified infections of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; aetiology of COVID-19) among recent international arrivals to Sudan and their contacts.

METHODS

Suspected cases were identified clinically and/or epidemiologically. Samples from suspected cases and their contacts were tested in the National Influenza Centre following World Health Organization protocols. Two real-time reverse transcription quantitative polymerase chain reaction assays were used to detect and confirm SARS-CoV-2 infection.

RESULTS

Seven cases of COVID-19, including two deaths, were confirmed in Sudan between 27 February and 30 March 2020. Suspected cases were identified and tested. As of 30 March, no local transmission was yet reported in the country. Fifty-nine percent of the suspected cases were international travellers coming from areas with current COVID-19 epidemics. Cough and fever were the major symptoms, presented by 65% and 60% of the suspected cases, respectively. By early April, an additional seven cases were confirmed through limited contact tracing that identified the first locally acquired infections in recent contact with imported cases.

CONCLUSIONS

The high mortality rate of COVID-19 cases in Sudan might be due to limitations in test and trace and case management services. Unfortunately, infections have spread further into other states and the country has no capacity for mass community screening to better estimate disease prevalence. Therefore external support is urgently needed to improve the healthcare and surveillance systems.

Building resilient and responsive research collaborations to tackle antimicrobial resistance-Lessons learnt from India, South Africa, and UK

Research, collaboration, and knowledge exchange are critical to global efforts to tackle antimicrobial resistance (AMR). Different healthcare economies are faced with different challenges in implementing effective strategies to address AMR. Building effective capacity for research to inform AMR-related strategies and policies is recognised as an important contributor to success. Interdisciplinary, intersector, as well as international collaborations are needed to span global to local efforts to tackle AMR. The development of reciprocal, long-term partnerships between collaborators in high-income and in low- and middle-income countries (LMICs) needs to be built on principles of capacity building. Using case studies spanning local and international research collaborations to codesign, implement, and evaluate strategies to tackle AMR, we have evaluated and build upon the ESSENCE criteria for capacity building in LMICs. The first case study describes the local codesign and implementation of antimicrobial stewardship (AMS) in the state of Kerala in India. The second case study describes an international research collaboration investigating AMR surgical patient pathways in India, the UK, and South Africa. We describe the steps undertaken to develop robust, agile, and flexible AMS research and implementation teams. Notably, investing in capacity building ensured that the programmes described in these case studies were sustained through the current severe acute respiratory syndrome coronavirus pandemic. Describing the strategies adopted by a local and an international collaboration to tackle AMR, we provide a model for capacity building in LMICs that can support sustainable and agile AMS programmes.

Why social accountability of medical schools in Sudan can lead to better primary healthcare and excellence in medical education?

Introduction:

Medical education in Sudan continues to evolve and progress with proliferation in the number of medical schools after 1990. Social factors and the geographical location of Sudan will increase the opportunity of success of medical schools to be socially accountable. In this analysis, we explained why social accountability is needed in Sudan and how this can enhance both excellence in medical education and primary health care, especially in rural areas.

Methodology:

PubMed, scopus Medline, and Google Scholar were searched for published-English literature concerning social accountability of medical schools in Sudan and worldwide were reviewed regardless of the time limit. We have also included examples of medical schools from Sudan and the Middle East to reflect on their experience in social accountability.

Results:

In this critical review, we have shown that social accountability will come with benefits for medical schools and the community. Implementation of social accountability in medical schools in Sudan will increase the effectiveness of medical schools' productivity, research output, and health service in urban and rural areas. There is an urgent need for social accountability alliance in Sudan to increase collaboration between medical schools. This will increase the benefits of social accountability for all stakeholders and also increases the competency in social medicine within the medical school curriculum.

Conclusion:

Social accountability is regarded as a sign of excellence in medical education. Primary care physicians in Sudan are expected to be the leaders in the implementation of social accountability. This analysis answered two important questions about why medical schools in Sudan should be socially accountable? And do we need a special structure of social accountability in Sudan?