Overview of malaria situation in Sudan

INTRODUCTION

Malaria is the most prevalent vector borne disease worldwide. It is endemic in 92 countries worldwide; and poses a major public health problem to over 600 million Africans. Malaria control is recognized as critical to achieving the Millennium development goals. In endemic regions in Africa which bear the greatest burden, the disease pathogen is continuously present in the community.^1,2

Worldwide, approximately 41% of the population is at risk, of malaria, with nearly 300 million to 500 million clinical cases of malaria, being reported every year. More than 90% of these cases are in Africa. Approximately, 2 million deaths can be attributed to malaria every year all over the world. Half of these deaths occur in children under 5 years of age.²

The country of Sudan has been known for its long history of wars, poverty, and disease. These multiple factors combine to cause a high incidence of morbidity and mortality, besides the inability of the population to seek and receive medical care.³ Malaria in Sudan affected more than two million people in Sudan in 2005. It is the number one killer in the country. Malaria being endemic to most of Sudan; 75% of the population lives daily with the risk of contracting it. Malaria contributes to 30% of hospital admissions and 16% of hospital deaths. As compared to other age groups., children below 3 years are at three to four times higher risk of death due to malaria than.⁴ Malaria is considered endemic in low-altitude Aweil east county (Bahr el Ghazal state, Southern Sudan). Most cases occur from July through January after spring rains.⁵

METHODS

General settings

Sudan located in north eastern Africa, (15^o 00’ N, 30^o 00’ E) is the largest country in Africa and the Arab world; and the 10^th largest in the world. The world's longest river, the Nile, divides the country between east and west sides. The terrain is generally flat, featureless plain; broken by several mountain ranges in the far northeast and west; while desert dominates the north. The blue and white Niles meet in Khartoum to form the river Nile, which flows northwards through Egypt to the Mediterranean Sea. The amount of rainfall increases towards the south. In the north there is the very dry Nubian desert; in the south there are swamps and rainforests. Sudan’s rainy season lasts for about three months (July to September) in the north, and up to six months (June to November) in the south. The climate is tropical in the south; arid desert in the north. The overall environment is thus very conducive for mosquito proliferation, survival and longevity and also favours active malaria transmission satellite terrain map of Sudan is presented in (Figure 1).

Research design

The study design was a retrospective cohort study design. Data collection: data for this overview were identified by searches of Medline, current contents, and references from relevant articles. Search terms were ‘Malaria’ and ‘Sudan’. The study was carried out from May 2010 to Jun 2011.

Approval of the Institutional Ethical Committee was obtained prior to commencement of the study. Data on morbidity and mortality attributable to malaria for the past two decades was collected by visits to local hospitals, Ministry of health, Govt. of Sudan, various International organizations employed in humanitarian missions in Sudan such as WHO, UN, UNICEF, and several NGOs. The data presented here pertains to the local population of Sudan for the period 1990 to 2008. Data from all sources was validated, compiled and analysed statistically using standard statistical tests.⁶ The same was taken into account to measure morbidity and mortality attributable to malaria.

Statistical analysis

Data from all sources was validated, compiled and analysed statistically using standard statistical tests.

RESULTS

Overall malaria incidence shows a significantly decreasing trend during the period of study with a slight increase in the years 1992, 1993, 1998, and 2005 to 2007. Chi square for linear trend= 37575204.31; p= 0 (Figure 2).

Data on incidence of malaria infections amongst the local population of Sudan for the period 1990 to 2008 is tabulated in (Table 1).^7,8

Data on disease burden/mortality attributable to malaria as a proportion of all consultations/deaths amongst local population of Sudan for the period 2000 to 2008 is presented in (Table 2).⁸

Over the nine years period, it was observed that 12.11% to 33.19% of all consultations was attributable to malaria. Disease burden due to malaria as proportion of all consultations also shows a generally significantly decreasing trend during the period of study with a slight increase in the years 2001, 2003, 2005 and 2006 (Chi square for linear trend= 4293305.45; p=0) (Figure 3). Mortality attributable to malaria ranged from 1.72% to 7.04%. Mortality attributable to malaria as a proportion of all deaths also shows a generally decreasing trend with a slight increase in 2008. Chi square for linear trend= 1096.140; p=0) (Figure 4).

DISCUSSION

A review of the federal health Canada databases for the incidence of malaria in Canada , from 1990 through 2002 , documents a range from 364 to 1,029 cases per year , with an average of 538 cases per year during the period (or an average of ≈1.8 cases per 100,000 population per year).⁹ This is much lower than the incidence in the present study. This study also contrasts with that conducted by Singh PMP, Bhalwar, Mehta, Mahendraker, Mehta. wherein the incidence of malaria showed a statistically significant increasing trend from 2000 to 2006 amongst army units deployed in Assam.¹⁰ Periodic epidemics of malaria are a major public health problem for many sub - Saharan African countries as well.¹¹ Experiences in Kisii, Gucha, Ayana, Gutten, and Damot Gale probably reflect conditions in neighboring regions affected by the corresponding epidemics, although scarcity of published records makes comparisons difficult.¹² In high altitude zones of western Kenya , clinical malaria has an acutely seasonal distribution ; and is a substantial public health problem every year.¹³ Sudan is a country known for its long history of wars, poverty, and disease. These factors combine to cause a high incidence of morbidity and mortality and the inability of the population to seek and receive medical care.³ The number one killer in Sudan is malaria, which affected more than two million people in 2005. Malaria is endemic to most of Sudan; 75% of the population lives daily with the risk of contracting it.⁴ The epidemiology of malaria infection and disease risks are in transition is some parts of Africa, in part as a result of scaling of the provision of insecticide treated nets (ITN) and adoption of new effective therapeutics.¹⁴ In 1998, with the support of WHO, the government initiated a plan to revitalize malaria control. In 2001, a national 10 years strategic plan was developed; in 2002, the Malaria free initiative was launched; in 2003, a plan was developed for scaling up the use of ITNs including using communication for behavioural impact; and in 2004 a national policy for control of malaria in pregnancy was initiated. Also, in 2004, the national drug policy was updated to use the ACT ASU+SP for first-line treatment.⁷ In these areas, the malaria control programme distributed over 3.3 million long lasting insecticide impregnated nets between 2006 and 2008. About 90% of public health facilities provide ACTs free of charge; in 2008, about 3 million treatment courses were delivered, enough to treat all reported cases. During the past 5 years, the Government has allocated more than US$ 31 million for malaria control, complemented by more than US$ 69 million from the global fund.⁸ Malaria reporting from national surveillance systems varies in quality and reporting completeness and may have limited value in understanding the actual malaria burden, but may be useful for understanding trends in the relative burden of malaria in the public health sector.⁷

More and more of those working in the government and other important positions are recognizing the crucial need for improving the health care system in all areas and are working to bring about this change.¹⁵ For 1 billion people at risk of unstable malaria transmission, elimination is epidemiologically feasible, and large areas of Africa are more amenable to control than appreciated previously.¹⁶

Limitations

The data presented here is only strongly suggestive of the trend of malaria amongst the local population of Sudan. It is quite probable that few cases would have been missed due to inadequacies of the reporting system. This analysis relies on programmatic data, the limitations of which are apparent. The data presented in this study pertains to the country of Sudan, before it was separated into two nations viz North Sudan and South Sudan in 2011.

CONCLUSION

The study attempts to highlight the trend of malaria amongst the local population of Sudan over last nearly two decades. Various important topographical, operational, socioeconomic, political and environmental factors contributing to the high incidence of malaria in this population have been discussed. The study population though comprising of the local population of Sudan is also suggestive of trends in other countries of the African continent.

Recommendations

Based on the findings of the study the following recommendations are submitted: areas at risk for epidemics through the influx of infected people should be identified to avoid or control epidemics. Particular attention should be paid to urban areas, given the ongoing trend towards uncontrolled urbanization. The risk for increased malaria transmission through economic development of an area should be analyzed thoroughly before development begins. Surveillance should be strengthened, which would help to prevent the reintroduction of malaria transmission by local mosquitoes, which could acquire the infection by biting persons with airport or imported malaria.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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