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Background: Malaria and dengue are common mosquito-borne diseases around the world that cause high mortality and morbidity. The number of cases of both diseases is currently rising in Sudan and is associated with climate and environmental changes. Limited information is available on malaria and dengue co-infections and the severity of the two diseases among febrile patients in eastern Sudan. Thus, this study aimed to estimate the prevalence of malaria and dengue co-infections among febrile patients in Kassala, eastern Sudan. Methodology/Principal findings: A cross-sectional hospital-based study was conducted among febrile patients from September to December 2019. A total of 395 patients were enrolled after consenting to participate in the study. Demographic and clinical data were collected by structured questionnaires. Blood samples were provided to diagnose malaria infections using microscopy and polymerase chain reaction (PCR) and for serology diagnosis of dengue using enzyme-linked immune sorbent assay (ELISA) IgM. Multiple logistic regression analysis was used to assess the association between demographic information, clinical symptoms and malaria and dengue co-infections. Out of 395 febrile patients examined 158 (40%) were malaria positive and 67 (17%) were dengue positive. The prevalence of malaria and dengue co-infections was 6.6% (26/395). Results of multiple logistic regression indicated that elder patients (41–60 years) had less rate of co-infections (OR = 0.3, 95% CI 0.11 to 0.81, p-value = 0.018), while patients of co-infections were eight times more likely to have fatigue, and two times more likely to suffer from joint and muscle pain and this difference was statistically significant with (OR = 8.3, 95% CI: 1.89 to 37.22, p-value = 0.005) and (OR = 2.4, 95% CI 1.10 to 5.39, p-value = 0.027), respectively. Conclusions/Significance: This study confirmed the existence of malaria and dengue co-infections among febrile patients in Kassala, eastern Sudan for the first time. The severity of clinical symptoms of patients with malaria and dengue co-infections was observed, and the co-infections were found prevalent among young people. Author summary: Malaria and dengue are common vector-borne diseases in eastern Sudan. However, co-infections with these two diseases are not reported among febrile patients. Malaria and dengue co-infections need a particular concern because this may increase morbidity and mortality if there are delays in diagnosis and appropriate treatment. So, this study has investigated the prevalence of malaria and dengue co-infections among febrile patients in Kassala, eastern Sudan. The findings of the study showed the prevalence of malaria and dengue co-infections in the study area according to the gender and age of enrolled patients. Results also showed the severity of clinical symptoms of patients with malaria and dengue co-infections were high compared to mono-infections, and the co-infections were found less among elder people. [ABSTRACT FROM AUTHOR]

In this communication, we reported a series of six patients presented with Guillain‐Barré syndrome that associated with COVID‐19 infection, which was confirmed with RT‐PCR. Here we discuss the laboratory investigation and case management, as well as clinical presentation and outcome of each case. The current report demonstrated the first case series of COVID‐19‐associated GBS‐cases in Sudan. [ABSTRACT FROM AUTHOR]

A cholera outbreak in Blue Nile and Sennar states, south-eastern and southern Sudan, took place during September–December 2019. An outbreak surveillance sample collection was made. Vibrio cholerae O1 Ogawa was isolated from clinical samples of all confirmed 200 and 132 cases in Blue Nile state and Sennar state, respectively. The case fatality rate was higher in Blue Nile state, 4% compared with only 2.3% in Sennar state. The Euvichol-Plus oral cholera vaccine was rapidly deployed for the first time in Sudan to the most at-risk populations in the two affected states, 1 471 188 and 1 546 542 individuals in Sennar and Blue Nile states, respectively. The rapid deployment of cholera vaccines as the major prevention and control strategy was successful and helped greatly with the containment of this epidemic. In-depth genomics studies are crucial for understanding the disease dynamics in Sudan by identifying locally circulating strains of the bacteria and further improving prevention and control strategy by characterising the susceptibility and resistance of these locally circulating strains to currently used antibiotics. [ABSTRACT FROM AUTHOR]

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic arboviral disease that poses a great threat to global health in the Old World, and it is endemic in Europe, Asia, and Africa, including Sudan. In this retrospective study, we reviewed previous epidemiological reports about the major epidemics of CCHF throughout Sudan between 2010 and 2020. During these epidemics, the infection of humans with Crimean-Congo hemorrhagic fever virus (CCHFV), the causative agent of CCHF, was diagnosed using qRT-PCR. We have identified 88 cases of CCHF, including 13 fatalities reported during five epidemics that occurred in 2010, 2011, 2015, 2019, and 2020. The two epidemics in 2010 and 2011 were by far the largest, with 51 and 27 cases reported, respectively. The majority of cases (78%) were reported in the endemic region of Kordofan. Here, we document that the first emergence of CCHFV in the Darfur region, West Sudan, occurred in 2010. We were not able to investigate outbreak dynamics through phylogenetic analysis due to the limited diagnostic capacity and the lack of sequencing services in the country. These findings call for establishing a genomic-based integrated One Health surveillance and response system for the early preparedness, prevention, and control of CCHF in the country. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has caused a severe depletion to health systems worldwide. In the South Kordofan state, a war-torn humanitarian region in Sudan, the United Nations High Commissioner for Refugees and the WHO Emergencies Programme have led the development of integrated programs for health, peace and rehabilitation by training rapid response teams to strengthen both surveillance system and response capacities, engaging the communities at risk with health education and promotion activities, as well as following proper infection, prevention and control measures during case investigation. Also, Early Help Assessment coordinators met with health services managers and recruited 14 teams who were trained to ensure a rapid response to COVID-19. Also, the implementation of water, sanitation and hygiene services was upscaled. Although the local community of South Kordofan is fragile and at high risk of infectious diseases, the limited numbers of detected cases of COVID-19 and COVID-19 deaths could be attributed to the early preparation and integration of programs that helped to prevent the local spread of COVID-19. This lesson needs to be thoroughly investigated to estimate whether it is cost-effective and to determine the feasibility of it being successfully implemented in other humanitarian settings. [ABSTRACT FROM AUTHOR]

Background: The currently used malaria vaccine, RTS,S, is designed based on the Plasmodium falciparum circumsporozoite protein (PfCSP). The pfcsp gene, besides having different polymorphic patterns, can vary between P. falciparum isolates due to geographical origin and host immune response. Such aspects are essential when considering the deployment of the RTS,S vaccine in a certain region. Therefore, this study assessed the genetic diversity of P. falciparum in Sudan based on the pfcsp gene by investigating the diversity at the N-terminal, central repeat, and the C-terminal regions. Methods: A cross-sectional molecular study was conducted; P. falciparum isolates were collected from different health centres in Khartoum State between January and December 2019. During the study period, a total of 261 febrile patients were recruited. Malaria diagnosis was made by expert microscopists using Giemsa-stained thick and thin blood films. DNA samples were examined by the semi-nested polymerase chain reaction (PCR). Single clonal infection of the confirmed P. falciparum cases, were used to amplify the pfcsp gene. The amplified amplicons of pfcsp have been sequenced using the Sanger dideoxy method. The obtained sequences of pfcsp nucleotide diversity parameters including the numbers of haplotypes (Hap), haplotypes diversity (Hapd), the average number of nucleotide differences between two sequences (p), and the numbers of segregating sites (S) were obtained. The haplotype networks were constructed using the online tcsBU software. Natural selection theory was also tested on pfcsp using Fuand Li's D, Fuand Li's F statistics, and Tajima's D test using DnaSP. Results: In comparison with the different pfcsp reference strains, the Sudanese isolates showed high similarity with other African isolates. The results of the N-terminal region showed the presence of 2 different haplotypes with a Hapd of 0.425 ± 0.00727. The presence of the unique insertion of NNNGDNGREGKDEDKRDGNN was reported. The KLKQP motif was conserved in all the studied isolates. At the central repeat region, 11 haplotypes were seen with a Hapd of 0.779 ± 0.00097. The analysis of the genetic diversity in the C-terminal region showed the presence of 10 haplotypes with a Hapd of 0.457 ± 0.073. Several non-synonymous amino acids changes were also seen at the Th2R and the Th3R T-cell epitope regions including T317K, E317K, Q318E, K321N, I322K, T322K, R322K, K324Q, I327L, G352N, S354P, R355K, N356D, Q357E, and E361A. Conclusions: In this study, the results indicated a high conservation at the pfcsp gene. This may further contribute in understanding the genetic polymorphisms of P. falciparum prior to the deployment of the RTS,S vaccine in Sudan. [ABSTRACT FROM AUTHOR]

Introduction: Malaria remains one of the most common public health problems worldwide, especially in Sudan. With this short communication we aimed at reporting on the latest malaria epidemic that had occurred in the humanitarian settings in South Kordofan state, south-western Sudan, during 2018 and 2019. Methodology: This is a cross-sectional study analyzing malaria surveillance reports between February 2018 to September 2019. Malaria was reported from febrile patients with confirmed malaria diagnosis using Giemsa stain. According to age, patients were distributed across three categories: less than 5 years, 5 to 15 years, and more than 15 years. Results: In 2019 and 2018, 63,214 and 63,224 cases of malaria were reported, respectively, constituting around 5.5% of the state population (1,152,900). In 2018, 3,571 malaria cases were reported in February, then they decreased in August followed by increase in September-October. In 2019, 15,610 malaria cases were reported in September. Malaria cases aged less than 5 years were 21,848 and 23,561 cases in 2018 and 2019, respectively. Conclusions: The reported sudden epidemic of malaria is alarming. Therefore, identifying the risk factors associated with this epidemic is crucial to malaria prevention and control, and hence successful achievement of malaria elimination. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: Malaria infection is still known to be a worldwide public health problem, especially in tropical and sub-tropical African countries like Sudan. A pilot study conducted to describe the trend of P. falciparum drug resistance markers in 2017–2018 in comparison to CQ and AS/SP eras in Sudan. The Pfcrt, Pfmdr-1, Pfdhfr, and Pfdhps genes were investigated. Data deposited by the worldwide antimalarial resistance network was consulted, and the molecular markers previously reported from Sudan were analyzed. Results: Drug molecular markers analysis was successfully done on 20 P. falciparum isolates. The Pfcrt K76 showed high frequency; 16 (80%). For the Pfmdr-1, 9 (45%) isolates were carrying the N86 allele, and 11 (55%) were 86Y allele. While the Y184F of the Pfmdr-1 showed a higher frequency of 184F compared to Y184; 16 (80%) and 4 (20%), respectively. In the Pfdhfr, 51I allele showed higher frequency compared to N51; 18 (90%) and 2 (10%), respectively. For S108N, 18 (90%) were 108 N and 2 (10%) were S108. In the Pfdhps, all isolates were carrying the mutant alleles; 437G and 540E. The frequency distribution of the Pfcrt, Pfmdr-1, Pfdhfr, Pfdhps was significantly different across the whole years in Sudan. [ABSTRACT FROM AUTHOR]

Objectives. The aim of this study was to assess frequency of lung epithelial atypia among Shisha users. Methods. Sputum samples were collected from200 subjects (100 Shisha users (cases) and 100 nontobacco users (controls)). Cytological smears were prepared and demonstrated using Papanicolaou and silver nucleolar organizer region (AgNORs) methods. Results. Cytological atypia was identified among 2/100 (2%) of the cases, and no cytological atypia was found among controls. Respiratory squamous metaplasia was significantly higher among cases 42/100 (42%), compared to controls 7/100 (7%) (P < 0.001). Shisha users were found more susceptible for bacterial infections 34 (34%) compared to controls 3/100 (3%), (P < 0.0001). The mean AgNOR dots count was higher among cases (2.3 ± .23) than among controls (1 ± .2), P < 0.001. Conclusion. In view of these findings, the consumption of Shisha is a risk factor for cellular proliferation activity in respiratory epithelium. The mean AgNORs count is a useful indicator for prediction of the risk of exposure to certain carcinogenic elements that may induce lung cancer. [ABSTRACT FROM AUTHOR]

We report an outbreak of dengue in Darfur, western Sudan, during September 2014-April 2015. Dengue virus-specific PCR testing of 50 samples from nonmalaria febrile illness case-patients confirmed 35 dengue cases. We detected 7 cases of dengue shock syndrome and 24 cases of dengue hemorrhagic fever. [ABSTRACT FROM AUTHOR]

This study aimed to investigate an outbreak of a non-malaria, undifferentiated febrile illness, among internally displaced persons (IDPs) living in humanitarian camps in North Darfur, Sudan, in 2019. An investigation team was deployed to North Darfur to identify suspected cases and collect blood samples, and clinical and demographical data. Blood samples were examined microscopically for Plasmodium spp and tested for dengue (DENV) and yellow fever viruses by reverse transcriptase-quantitative polymerase chain reaction. Between September 7 and December 18, 2019, we clinically identified 18 (24%), 41 (54%), and 17 (22%) cases of dengue fever, dengue with warning signs, and severe dengue, respectively. Blood samples were collected from 22% of patients, and 47% of these tested positive for DENV-1 RNA. We confirmed 32 malaria cases with 5 co-infections with DENV. This outbreak of dengue was the first among IDPs in the humanitarian camps. Our findings indicate that dengue has become endemic or that there has been a new introduction. Further epidemiological, entomological, and phylogenetic studies are needed to understand disease transmission in the area. An early warning and response system and an effective health policy are crucial for preventing and controlling arboviruses in Sudan. [ABSTRACT FROM AUTHOR]

The impacts of COVID -19 pandemic have been quite significant on healthcare providers. I was particularly challenging for those in Low and Middle-Income Countries including Sudan . Unfortunately, the pandemic has hit Sudan on extremely difficult time for the country and its people. The country was coming out of long-brutal and devastating dictatorship and transitioning to new democracy with civilian leadership. In addition to the pandemic related issues, trying to rebuild the health system during socioeconomic crisis, healthcare providers in the country were challenged personally and professionally. These challenges include the stress of working in under-resourced settings with limited access to personal-protection equipment and testing kits raised the fear of contracting the virus and spreading it to their families. The professional, social, and personal life of healthcare providers have been dramatically changed by the ongoing pandemic, however, they are heroically accepting this change in a hope that, this will save the life of many more people. Nevertheless, their fights and sacrifices should at least be rewarded by governments and communities altogether strictly enforce the implementation of other preventive measures including vaccination, face masking, and social distancing and get all protected. We should all understand that, unless we are all protected no one is protected, so all must adapt to the new norm of life and collaborate not only on ending this pandemic but to prevent similar ones in the future. [ABSTRACT FROM AUTHOR]

Assessing the COVID-19 surveillance system is vital. It identifies cases swiftly and is crucial in curbing COVID-19 spread, especially among vulnerable groups. Public health surveillance collects, analyzes, and shares data systematically, informing actions to lessen disease impact. Here we used a mixed-approach method to assess the COVID-19 surveillance system in Sudan by reviewing the secondary data (line list) from January 28, 2020 to November 2, 2022. The system's effectiveness was rated weak based on the poor quality and incompleteness of the collected data, as well as the reporting process to policymakers and responders. Moreover, the system's acceptability score was low, mainly because of the incompleteness and delays in data reported from the private sector. This assessment recommends that the Federal Ministry of Health invest in improving the surveillance system by building the technical capacity of the staff, infrastructure, and utilization of the District Health Information Software-2 for data collection, analysis, and dissemination.

Background: On April 15, 2023, the armed conflict between the Sudanese Armed Forces (SAF) and the Rapid Support Forces (RSF) started in Khartoum state, Sudan. This conflict was complicated by the preexisting complicated epidemiological situation and fragile health system in Sudan. This study endeavors to illuminate the pivotal role essayed by the Sudan FETP (SFETP) in enhancing the nation's public health response, particularly amidst the tumultuous backdrop of armed conflicts that have left their indelible mark on the region., Methods: Employing a blend of quantitative and qualitative methodologies, we investigated the SFETP's contributions to the public health response during the initial 4 months of the conflict (April-July 2023). Sixty-four SFETP residents and graduates were invited to participate, and data were gathered through semi-structured questionnaires., Results: A total of 44 (69%) SFETP residents and graduates were included in this study. Out of 38 SFETPs present in the states, 32 have considerably contributed to the crisis response at state and locality levels. Three-quarters of them have played key leadership, planning, and management roles. In essence, 38% ( n = 12) of them have contributed to public health surveillance, particularly in data management, reports, Early Warning Alert and Response System (EWAR) establishment, and epidemic investigation. SFETPs have made special contributions to crisis response at the community level. The involved SFETPs supported WASH interventions ( n = 4), and almost one-third of them strengthened risk communication and community engagement ( n = 9). Despite their physical presence at the subnational level, 27% of graduates were not deployed to the crisis emergency response. Notably, throughout this time, half of the total SFETPs were formally retained during this response., Conclusion: The study highlighted the importance of FETP engagement and support during public health crises. SFETP residents and graduates played diverse roles in the various levels of public health emergency response to the crisis. However. Strategies to improve the deployment and retention of FETP residents are necessary to ensure their availability during crises. Overall, FETP has proven to be an asset in public health crisis management in Sudan., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Khairy, Bashier, Nuh, Ahmed, Ali, Izzoddeen, Mohamed, Osman and Khader.)

Background: Dengue and chikungunya are mosquito-borne infections that are spreading rapidly worldwide. The highest burden lies in tropical and subtropical countries. In 2022 Sudan encountered the most widespread infection of both diseases., Aim: To describe the magnitude of the first outbreak of dengue and chikungunya infections in Tandalti Town, White Nile State, southern part of Sudan., Methods: Following the report of a high number of undifferentiated febrile illnesses in 32 health clinics in Tandalti Town, an area with high densities of Aedes aegypti, we collected blood samples from symptomatic suspected cases. The samples were tested for major arboviral infections using arboviral-specific enzyme-linked immunosorbent assays (IgM capture ELISA), and serologically positive samples were confirmed using commercially available Real Time RT-PCR Kits., Results: Out of 773 suspected cases, 63 (8.15%) were confirmed. Eleven (17.46%) of the confirmed cases were DENV, 49 (77.77%) were CHIKV, and 3 (4.76%) were DENV and CHIKV co-infections. The outbreak started at the beginning of October and ended by mid December 2022. Both dengue and chikungunya infection was higher (41(65.08%)) among young females than males (22 (34.92%))., Conclusions: White Nile State may experience larger outbreaks of dengue and chikungunya in the future, there is, therefore, an urgent need for proper vector control interventions in the state and nearby states., (Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Background: Cervical cancer is considered the third leading cause of death among women worldwide, and human papillomavirus was identified as a major causative agent for developing cervical cancer., Objectives: This study aimed to assess the knowledge and attitudes towards cervical cancer prevention among women in Khartoum state, Sudan., Design: A community-based cross-sectional study implemented in Khartoum state, Sudan, from 1 August 2020 to 1 September 2020., Methods: We conducted a descriptive cross-sectional community-based study using an electronic questionnaire for data collection. Descriptive statistics, frequency, mean, and percentage were computed., Results: The study included 716 female participants with a mean age of 27.6 + 8.7 years. 580 (81.0%) and 229 (32.0%) had heard about cervical cancer and Pap test, respectively. cervical cancer was assumed related to alcohol consumption 109 (15.2%), giving birth to many children 51 (7.1%), ageing 118 (16.5%), and having many sexual partners 335 (46.8%). In addition, 300 (41.9%) attributed cervical cancer to having human papillomavirus infection, 256 (35.6%) to the prolonged use of contraceptives, and 162 (22.6%) to smoking. Knowledge about the best time to be vaccinated against human papillomavirus, 110 (15.4%) stated it is better after marriage. Regression models to predict the effectors on participants' knowledge and attitudes showed a low standard deviation of the estimates with higher values of the adjusted R 2 [R: 0.041, 0.017, and 0.006; std: 1.527, 0.417, and 0.426]. This indicates the combined influence of occupation, educational level, family income, and marital status on the participant's knowledge and attitude levels., Conclusion: This study revealed that the participant's knowledge and attitudes levels are mainly driven by their occupation, educational level, family income, and marital status altogether. This underscores the need for a countrywide community engagement campaign through health education and raising awareness sessions, and massive social media to sensitize the community and healthcare providers about the risk of cervical cancer and the available prevention and control measures.

We report hepatitis E virus (HEV) outbreaks among refugees from Ethiopia in Sudan during June 2021-February 2022. We identified 1,589 cases of acute jaundice syndrome and used PCR to confirm HEV infection in 64% of cases. Implementing vaccination, water, sanitation, and hygiene programs might reduce HEV outbreak risk.

We report a unique outbreak of Rift Valley fever in the Eldamar area, Sudan, May-July 2019, that resulted in 1,129 case-patients and 19 (1.7%) deaths. Patients exhibited clinical signs including fever (100%), headache (79%), and bleeding (4%). Most (98%) patients also reported death and abortions among their livestock.