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Background: Various international guidelines have been developed regarding Helicobacter pylori (H. pylori) management, as it is infecting more than half of the world's population. Sudan's health system lacks guidelines regarding H. pylori management, leading to a discrepancy in practice. Investigating the current approach could be a step forward in the formulation of a national consensus in the management of H. pylori. Methods: A cross-sectional study was conducted among medical doctors currently working in Khartoum, Sudan. Participants were enrolled from platforms of medical associations through an online questionnaire. The questionnaire was scored out of 25 points, and scoring 13 or above considered a good approach. Data analysis was carried out using Statistical Package for Social Sciences (SPSS). Results: A total of 358 medical doctors participated in the study. The mean (±SD) score was 12.9(±4.5). Those who were using textbooks, campaigns, symposiums or general medical information to their primary Source of knowledge significantly scored higher. The most selected indication for both diagnosis (76.8%) and treatment (67.6%) was an active peptic ulcer. Stool antigen test (SAT) was the most preferred test (70.7%). The majority of respondents selected triple therapy (82.1%) as a first-line regimen. Only 37.7% confirmed the eradication after four weeks of stopping the treatment. They ensure eradication mainly through SAT (29%). Conclusion: A suboptimal approach was noted among medical doctors of Khartoum, Sudan, regarding H. pylori management. Efforts should be invested in forming national guidelines and the implementation of continuous medical education programs. Keywords: Helicobacter pylori, Medical doctor, Sudan.

Various international guidelines have been developed regardingA cross-sectional study was conducted among medical doctors currently working in Khartoum, Sudan. Participants were enrolled from platforms of medical associations through an online questionnaire. The questionnaire was scored out of 25 points, and scoring 13 or above considered a good approach. Data analysis was carried out using Statistical Package for Social Sciences (SPSS).A total of 358 medical doctors participated in the study. The mean (±SD) score was 12.9(±4.5). Those who were using textbooks, campaigns, symposiums or general medical information to their primary Source of knowledge significantly scored higher. The most selected indication for both diagnosis (76.8%) and treatment (67.6%) was an active peptic ulcer. Stool antigen test (SAT) was the most preferred test (70.7%). The majority of respondents selected triple therapy (82.1%) as a first-line regimen. Only 37.7% confirmed the eradication after four weeks of stopping the treatment. They ensure eradication mainly through SAT (29%).A suboptimal approach was noted among medical doctors of Khartoum, Sudan, regarding

Background: Community engagement has proved effective in increasing access to healthcare including health insurance, in developed and developing countries. Aim: The study aims at designing and testing the effectiveness of engaging the community in awareness-raising and increment of health insurance coverage. Methods: The study was a social interventional community-based study, conducted in A-Duiem Administrative Unit, A-Duiem Locality, Sudan. Baseline data on enrollment in health insurance was collected from 800 heads of households, whereas data on knowledge and attitudes about health insurance was collected from 420 heads of non-insured households using a standardized questionnaire. Strategies to scaleup health insurance through community engagement was collected from community leaders, local authorities, and health insurance policymakers through in-depth interviews and focus group discussions. The community promotion package of health insurance was implemented for one year and post-intervention data were collected from 420 heads of households. Quantitative data were analyzed using SPSS version 20. Statistical significance was set at p

Background Population knowledge and attitudes toward health insurance are important factors that facilitate health insurance coverage. National studies on these parameters are limited. Aim This study aims at assessing determinants of non-insurance in A-Duiem Administrative Unit and calculating as a secondary objective the household’s health insurance coverage. Methods The study was a descriptive cross-sectional community-based conducted in A-Duiem Administrative Unit, Sudan. It collected quantitative data from non-insured households and qualitative data by interviewing community leaders and conducting focus group discussions with community organizations members. Quantitative data analyzed using the Statistical Package for Social Sciences (SPSS) version 20, and the thematic analysis for the qualitative data. Results The study interviewed 419 non-insured households’ heads and thirteen community leaders and conducted eight focus group discussions with sixty community organizations members. Around 37.9% (95% CI: 33.4-42.7) of the heads of the non-insured households did not know the health insurance, while only 2.4% (95% CI: 1.5-4.7) had good knowledge. The knowledge of non-insured community leaders and members of the community organizations was moderate. The study participants showed positive attitudes towards health insurance, as 97% (95% CI: 95.1-98.4) of the heads of the non-insured households wanted to join the health insurance and 65% (95% CI: 59.2-70.1) of them stated that they could pay its premium. Most of the community leaders and members of the community organizations had health insurance cards. Those who were not enrolled, have limited knowledge about health insurance while almost all believe they should join it. The study identified 52.4% of non-insured households (95% CI: 48.9-55.8). The study showed low health insurance coverage among families, despite their positive attitude. This is mostly attributed to poor awareness of the heads of the non-insured households about health insurance. The National Health Insurance Fund (NHIF) should address this gap through effective communication strategies using motivated community institutions

Background The coronavirus disease 2019 (COVID-19) outbreak, started in the Hubei province of China in December 2019. On January 31, the World Health Organization (WHO) declared COVID-19 a worldwide pandemic. We wondered what countries in Africa and South-East Asia had done to prevent infectious disease, specifically, COVID-19, from impacting the population of specific countries in that region, and what disease control measures were successful. Expert reflections on findings could guide continued successful public health approaches in managing this complex infectious disease pandemic. Methods Using a scoping review, published papers, or program descriptions for specific geographic regions (i.e., Africa or Southeast Asia) were searched using specified key terms. Three targeted countries classified by World Bank as lower-middle-income in the two WHO selected regions [Africa (Sudan and Nigeria); Southeast Asia (India)] were reviewed with respect to COVID19 preparedness and response. Findings were organized, highlighting key points that seem particularly useful for regional learning. The evidence from each region was summarized in the aggregate to determine some common, noteworthy themes. COVID-19 epidemiologic data for these regions were also reviewed. Results Our findings indicate experience from prior infectious disease outbreak seems to have prepared the selected countries in their preparedness for COVID-19 outbreak on various levels. Incidence of COVID-19 increased across the selected countries. WHO recommended basic public health strategies to reduce disease transmission was ssinitiated by the selected countries at different levels. However, feasibility and lockdown practices raise public health concerns and questions across the target regions reviewed. Conclusion This scoping review and expert reflections uncovers important preparedness and responses to the COVID-19 pandemic in the selected WHO regions. Further exploration and possible public health strategic plans may be needed.

Background: Since the first case of COVID-19 in Sudan was reported in March 2020, the Federal Ministry of Health adopted an active surveillance system to collect and analyze information from the isolation centers and public and private laboratories about all suspected and confirmed COVID-19 cases. This study used the surveillance data to better understand the distribution and determinants of COVID-19 in Sudan and to construct a threshold level beyond which the dramatic surge may occur. Methods: Data of suspected and confirmed COVID-19 cases were extracted from the line list prepared by the Surveillance and Information Department at the Federal Ministry of Health after obtaining ethical approval from the National Ethics Committee. Data were cleaned, coded, and analyzed using SPSS version 21. Frequencies and proportions were used to describe data. A univariate logistic regression analysis was used to determine the association of variables with the positivity of COVID-19. Variables with p-values p Results: Out of 48,545 suspected cases, 27,453 were positive. Four waves were seen, with a distinct explosion point of around 200 cases observed nationwide. Khartoum reported the highest number of cases. Of those tested positive, 16,444 (59.9%) were male and 11,009 (40.1%) were female. The mean (SD) age of cases was 41.1 (19.0) years with 21.6% of cases above 60 years. 14,780 (53.8%) of cases were asymptomatic. Fever, cough, shortness of breath, and loss of smell and taste were reported in 32.7%, 26.4%, 19.1 and 4.5% of confirmed cases, respectively. A total of 1,793 confirmed cases died; the case fatality rate was 6.5%. A considerable proportion of infection was reported among health workers. A univariate logistic regression analysis revealed that being symptomatic is significantly associated with testing negative for COVID-19 (odds ratio < 1). Conclusions: COVID-19 was widely spread in Sudan with more cases in Khartoum, the capital of Sudan. The country experienced four waves with an observable epidemic explosion point of around 200 positive cases per week nationwide. Around half of the patients were asymptomatic; however, fever, cough, and shortness of breath were the commonest symptoms. The CFR all through was 6.5%, with death having a strong association with age. Further studies are recommended to clarify the image, especially among health workers. The study also highlighted the need to improve the quality of surveillance data.

Background Coronavirus disease 2019 (COVID-19) is a pandemic caused by a newly discovered coronavirus. Although clinical manifestations of COVID-19 are mainly pulmonary, some patients have other systemic manifestations. This study aimed to describe the clinical finding and outcomes in Sudanese patients diagnosed with COVID-19. Methods This retrospective observational study is based on documented files that included patients diagnosed with COVID-19 in seven selected hospitals inside Khartoum. Clinical manifestations, complications and outcomes were extracted from patients’ records using an extraction form designed for this study. Results Data of 243 patients diagnosed with COVID-19 were analyzed. The mean (SD) age in years was 55.8 (18.4). Out of 116 participants, 27 of them (23.3%) had severe disease, 15 (12.9%) were critically ill. 67.5% of patients were admitted to the hospital within 7 days from onset of symptoms; most of them were admitted to the wards (n = 140,72.5%). Fever (83.2%), cough (70.7%), and shortness of breath (69.2%) were the most commonly recorded clinical manifestations. Sepsis (9.8%) and acidosis (7.8%) were the most frequently reported complications. Death was the final outcome in 21.4% (56/243). Older age and presence of diabetes were found significantly associated with in-hospital death. The laboratory results showed high CRP in 85.6% (119/139), high ferritin in 88.9% (24/27), lactate dehydrogenase had a median of 409.0 (359–760), D-dimer had a median of 3.3 (1.2–16. 6), and 53/105 (50.5%) had low albumin. Conclusions Fever was the most mentioned sign among the participants, followed by fatigue. Cough and shortness of breath were the most commonly recorded pulmonary symptoms manifested. Our study showed multiple variables were associated with in-hospital death. The mortality rate was high among severe and critically ill patients diagnosed with COVID-19.

Background: Migraine is one of the most common types of headache; it is a chronic neurological disease that affects 15% of the population, however, information about its prevalence in Sudan is scarce. Aim: The aim of this study was to study prevalence of migraine and trigger factors among adult rural Sudanese population in 2018. Setting and Design: This is a cross sectional two-stage door-to-door community-based study conducted in 16 administrative areas in rural Sudan. Materials and Methods: A sample of 8610 adult Sudanese individuals, 18 years and above was selected. A structured pretested questionnaire was used included questions about two or more headaches in the last three months for screening. Participants with at least one positive response were asked to perform the 3-item validated Identification of Migraine (ID Migraine) test. Data was analyzed by SPSS version 20 for descriptive statistics and one way chi square test was used for testing the association of triggering factors with migraine at 95% confidence level of significant. Results: Four hundred and sixty eight had migraine with a prevalence rate of 5.4% among 8610 study population. The prevalence of migraine was 40% among those having at least two episodes of headache. Females were significantly affected by migraine more than males, P- value 0.044. Migraine significantly decreases with increase in age showed the highest frequency among the age group 18-29 years (38.0%). Family history of migraine accounted to 83.4% of population with migraine. Population with migraine who experienced aura was 64.5%. Already diagnosed population with migraine was 38.9%.The most important triggering factors among population with migraine were irregular/lack of sleep followed by stress/anxiety, noise and fatigue/physical activity, 91.0%, 88.0%, 85.7% and 84.6% respectively. The females experienced migraine with menstruation accounted to 46.7%. Perceived migraine effect was moderate to severe on work/ daily activities/ leisure of 78.2% of population with migraine. Conclusion: Migraine prevalence was alarming in this study. A gap exists in the diagnosis of migraine that needs efforts to reduce the sufferings of affected population.

Background Early childhood is an age at risk of anaemia and its deleterious consequences. In Sudan, there is limited evidence on the prevalence and determinant of anaemia in under-five children. This study was conducted in Sudan to assess the prevalence of anaemia in children and to identify its determinants. Methods We conducted a household survey involving children aged 6 months to 5 years in November 2016. A representative population was sampled across rural, urban and camps settlements across 18 states in Sudan. We used a pre-designed questionnaire data collection. Haemoglobin (Hb) level and malaria infection were checked. In this cross-sectional study, we dichotomized the outcome variable and performed logistic regression analyses. Results A total of 3094 children under 5 years enrolled in the study, 1566 (50.6%) of them were female and 690 (22.3%) of them were under 2 years old. Anaemia prevalence in the whole cohort (6 months - p p p = 0.005), maternal anaemia (OR 1.74, 95%CI 1.39–2.17, p p p = 0.008). However, in older children, three anaemia predictors were identified. These are maternal anaemia (OR 1.79, 95%CI 1.40–2.28, p = 0.002), and type of residency (where camps’ residents were less likely affected with anaemia than rural children (OR 0.38, 95%CI 0.17–0.87, p = 0.022)). Conclusions About half of the under-5 children in Sudan are anaemic, with worse prevalence in younger children. Efforts targeted at improving socio-economic status, decreasing maternal anaemia and childhood malaria infection may mitigate this alarming trend.

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.

The World Health Organization (WHO) declared the current COVID-19 a public health emergency of international concern on January 30, 2020. Countries in the Eastern Mediterranean Region (EMR) have a high vulnerability and variable capacity to respond to outbreaks. Many of these countries addressed the need for increasing capacity in the areas of surveillance and rapid response to public health threats. Moreover, countries addressed the need for communication strategies that direct the public to actions for self- and community protection. This viewpoint article aims to highlight the contribution of the Global Health Development (GHD)/Eastern Mediterranean Public Health Network (EMPHNET) and the EMR’s Field Epidemiology Training Program (FETPs) to prepare for and respond to the current COVID-19 threat. GHD/EMPHNET has the scientific expertise to contribute to elevating the level of country alert and preparedness in the EMR and to provide technical support through health promotion, training and training materials, guidelines, coordination, and communication. The FETPs are currently actively participating in surveillance and screening at the ports of entry, development of communication materials and guidelines, and sharing information to health professionals and the public. However, some countries remain ill-equipped, have poor diagnostic capacity, and are in need of further capacity development in response to public health threats. It is essential that GHD/EMPHNET and FETPs continue building the capacity to respond to COVID-19 and intensify support for preparedness and response to public health emergencies.

Background Plasmodium falciparum malaria is a public health problem worldwide. Malaria treatment policy has faced periodic changes due to emergence of drug resistant parasites. In Sudan chloroquine has been replaced by artesunate and sulfadoxine/pyrimethamine (AS/SP) in 2005 and to artemether–lumefantrine (AL) in 2017, due to the development of drug resistance. Different molecular markers have been used to monitor the status of drug resistant P. falciparum. This study aimed to determine the frequency of malaria drug resistance molecular markers in Southeast Sudan. Methods The samples of this study were day zero dried blood spot samples collected from efficacy studies in the Blue Nile State from November 2015 to January 2016. A total of 130 samples were amplified and sequenced using illumina Miseq platform. The molecular markers included were Pfcrt, Pfmdr1, Pfdhfr, Pfdhps, Pfk13, exonuclease and artemisinin resistant (ART‐R) genetic background (Pfmdr2, ferroredoxine, Pfcrt and Pfarps10). Results Resistance markers for chloroquine were detected in 25.8% of the samples as mutant haplotype Pfcrt 72-76 CVIET and 21.7% Pfmdr1 86Y. Pfdhfr mutations were detected in codons 51, 59 and 108. The ICNI double-mutant haplotype was the most prevalent (69%). Pfdhps mutations were detected in codons 436, 437, 540, 581 and 613. The SGEGA triple-mutant haplotype was the most prevalent (43%). In Pfdhfr/Pfdhps combined mutation, quintuple mutation ICNI/SGEGA is the most frequent one (29%). Six of the seven treatment failure samples had quintuple mutation and the seventh was quadruple. This was significantly higher from the adequately responsive group (P Pfk13 novel mutations were found in 7 (8.8%) samples, which were not linked to artemisinin resistance. Mutations in ART‐R genetic background genes ranged from zero to 7%. Exonuclease mutation was not detected. Conclusion In this study, moderate resistance to chloroquine and high resistance to SP was observed. Novel mutations of Pfk13 gene not linked to treatment failure were described. There was no resistance to piperaquine the partner drug of dihydroartemisinin/piperaquine (DHA-PPQ).

Summary Background Scale-up of insecticide-based interventions has averted more than 500 million malaria cases since 2000. Increasing insecticide resistance could herald a rebound in disease and mortality. We aimed to investigate whether insecticide resistance was associated with loss of effectiveness of long-lasting insecticidal nets and increased malaria disease burden. Methods This WHO-coordinated, prospective, observational cohort study was done at 279 clusters (villages or groups of villages in which phenotypic resistance was measurable) in Benin, Cameroon, India, Kenya, and Sudan. Pyrethroid long-lasting insecticidal nets were the principal form of malaria vector control in all study areas; in Sudan this approach was supplemented by indoor residual spraying. Cohorts of children from randomly selected households in each cluster were recruited and followed up by community health workers to measure incidence of clinical malaria and prevalence of infection. Mosquitoes were assessed for susceptibility to pyrethroids using the standard WHO bioassay test. Country-specific results were combined using meta-analysis. Findings Between June 2, 2012, and Nov 4, 2016, 40 000 children were enrolled and assessed for clinical incidence during 1·4 million follow-up visits. 80 000 mosquitoes were assessed for insecticide resistance. Long-lasting insecticidal net users had lower infection prevalence (adjusted odds ratio [OR] 0·63, 95% CI 0·51–0·78) and disease incidence (adjusted rate ratio [RR] 0·62, 0·41–0·94) than did non-users across a range of resistance levels. We found no evidence of an association between insecticide resistance and infection prevalence (adjusted OR 0·86, 0·70–1·06) or incidence (adjusted RR 0·89, 0·72–1·10). Users of nets, although significantly better protected than non-users, were nevertheless subject to high malaria infection risk (ranging from an average incidence in net users of 0·023, [95% CI 0·016–0·033] per person-year in India, to 0·80 [0·65–0·97] per person year in Kenya; and an average infection prevalence in net users of 0·8% [0·5–1·3] in India to an average infection prevalence of 50·8% [43·4–58·2] in Benin). Interpretation Irrespective of resistance, populations in malaria endemic areas should continue to use long-lasting insecticidal nets to reduce their risk of infection. As nets provide only partial protection, the development of additional vector control tools should be prioritised to reduce the unacceptably high malaria burden. Funding Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development.

Background Artemisinin-based combination therapy (ACT), together with other control measures, have reduced the burden of falciparum malaria in sub-Saharan countries, including Sudan. Sudan adopted ACT in 2004 with a remarkable reduction in mortality due to falciparum malaria. However, emergence of resistance to the first-line treatment artesunate and sulfadoxine/pyrimethamine (AS/SP) has created new challenges to the control of malaria in Sudan. A search for an alternative drug of choice for treating uncomplicated malaria has become inevitable. The objective of this study was to evaluate the therapeutic efficacies of dihydroartemisinin/piperaquine (DHA–PPQ) and AS/SP in an area of unstable transmission in Blue Nile State, Sudan in 2015–16. Methods A total of 148 patients with uncomplicated malaria were recruited in the study from November 2015 to end of January 2016. Seventy-five patients received DHA–PPQ while 73 received AS/SP. Patients were monitored for clinical and parasitological outcomes following the standard WHO protocol for a period of 42 days for DHA–PPQ and 28 days for AS/SP; nested PCR (nPCR) was performed to confirm parasite re-appearance from day 7 onwards. Results Fifty-five patients completed the DHA–PPQ arm protocol with success cure rate of 98.2% (95% CI 90.3–100%) and one late clinical failure 1.8% (95% CI 0.0–9.7%). The AS/SP showed adequate clinical and parasitological response (ACPR) of 83.6% (95% CI 71.9–91.8%), early treatment failure was 1.6% (95% CI 0.0–8.8%) and late parasitological failure (LPF) was 14.8% (95% CI 7–26.2%). The respective PCR uncorrected LPF was 20%. Conclusion DHA–PPQ is an efficacious ACT and candidate for replacement of first-line treatment in Sudan while AS/SP showed high treatment failure rate and must be replaced. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1817-9) contains supplementary material, which is available to authorized users.

Background Training of family physicians should include not only clinical and procedural skills, but also core values as comprehensive care, continuity of care, leadership and patient-centeredness. The Gezira Family Medicine Project (GFMP) is a 2 years Master’s programme in family medicine in Sudan. We assessed the impact of GFMP on the candidates’ adherence to some core values of family medicine. Methods This is a prospective study with before-after design based on repeated surveys. We used Patient-Practitioner Orientation Scale (PPOS) to assess physicians’ attitude towards patient-centeredness. Practice based data from individual patients’ consultations and self-assessment methods were used to assess physicians’ adherence to core values. Results At the end of the programme the candidates (N = 110) were significantly more active in community health promotion (p p = 0.008), and showed increased adherence to national guidelines for managing diabetes (p = 0.017) and hypertension (p = 0.003). The responding candidates had more knowledge about patients’ medical history (p p p p p = 0.040). In contrast, results from PPOS showed slightly less orientation towards patient-centeredness (p = 0.007). Conclusions The GFMP Master’s programme induced a positive change in adherence to several core values of family medicine. The candidates became less patient-centered.

Background The present study aimed to evaluate the management of severe malaria at Gezira State hospitals in Sudan by assessing hospital readiness, health care provider knowledge and the care received by severe malaria patients. Methods A cross-sectional descriptive study was performed to assess the severe malaria management practices at hospitals level in Gezira State. The study population included hospitals, health care providers and patients. Data was collected using checklists and structured questionnaires. Results A total of 20 hospitals, 158 health care providers and 370 patients were included in the study. Out of the total hospitals, 95% (19/20) were providing 24 h outpatient services, 65% (13/20) had ICU units, while triage system was found in only 35% (7/20) of hospitals. From all hospitals evaluated, 90% (18/20) were suffering from shortage of staff, especially doctors. About half of the health care providers (46.7%) did not receive severe malaria management training. The average knowledge score among health care providers was 55.4%. Microscopy was available in all hospitals (100%), while rapid diagnostic test, complete blood count and renal function test were available in 15 hospitals (75%). Fever was the most presenting symptom (97.8%) followed by repeated vomiting (51.4%), convulsion in children (24.3%) and prostration in adult (57.9%). Correctly diagnosed patients were 68.9%. Essential tests were done for only 11.1% of patients. Majority of patients (91.7%) were treated with quinine, 5.9% received artemether, while 2.4% were treated with artemether–lumefantrine. Those who received both the correct dose and dosing regimen were 53.8%. The overall compliance to guidelines was 2.2%. Conclusion This study highlights the fact that management of severe malaria at hospital level was suboptimal with serious shortcomings in the different aspects of care particularly in specialized hospitals. Technical staff was inadequate, hospitals were anguish from defective emergency services, and most patients were not treated according to the national guidelines. Electronic supplementary material The online version of this article (10.1186/s12936-019-2805-z) contains supplementary material, which is available to authorized users.

Background: This study aimed to assess the admission pattern and outcome of neonates managed in the neonatal intensive care unit (NICU) in a Sudanese hospital.Methods: This hospital-based retrospective study was conducted in the NICU of Saad Abu Elella Teaching Hospital in Khartoum, Sudan. Data was collected from medical records of 207 neonates using an extraction form. Chi-square test and binary logistic regression were used in analysis.Results: Most of the neonates were term, and 43% of them had a birth weight less than 2.5 kg. Moreover, the most common morbidities among them were sepsis, respiratory distress syndrome, neonatal jaundice and asphyxia, and the mortality rate was 15%. Additionally, the birth weight, gestational age, the need for resuscitations, direct breast feeding and being beside mother were found to be significantly associated with the studied outcome.Conclusions: Majority of causes of neonatal morbidity and mortality in our study were preventable diseases. Therefore, interventions to improve services in the NICU are highly needed to improve the outcomes.

Background The emergence of resistant parasites to artemisinin poses a threat to malaria treatment. The study aimed to investigate K13 gene mutations in Plasmodium falciparum artesunate (AS)/sulfadoxine-pyrimethamine (SP) efficacy study in Sudan. Methods A total of 31 (14 failures and 17 adequate clinical and parasitological response [ACPR]) pretreatment dried blood samples from patients with uncomplicated P. falciparum malaria treated with AS/SP were examined. Nested polymerase chain reaction (PCR) and DNA sequencing of the K13 gene was performed. Results PCR products were obtained from 30 (96.8%) samples and sequencing was successful in 28 (90.3%). No mutation of the K13 gene was recorded in the treatment failure group. A single mutation (C>T; A621V) in one ACPR patient sample was detected. Conclusion There is no evidence of K13 mutation among AS/SP treatment failure patients. A single mutation of the K13 gene not linked to treatment failure has been detected.

Information and communication technology (ICT) is progressively used in the health sector (e-health), to provide health care in a distance (telemedicine), facilitate medical education (e-learning), and manage patients’ information (electronic medical records, EMRs). Gezira Family Medicine Project (GFMP) in Sudan provides a 2-year master’s degree in family medicine, with ICT fully integrated in the project. This cross-sectional study describes ICT implementation and utilization at the GFMP for the years 2011-2012. Administrative data was used to describe ICT implementation, while questionnaire-based data was used to assess candidates’ perceptions and satisfaction. In the period from April 2011 to December 2012, 3808 telemedicine online consultations were recorded and over 165000 new patients’ EMRs were established by the study subjects (125 candidates enrolled in the program). Almost all respondents confirmed the importance of telemedicine. The majority appreciated also the importance of using EMRs. Online lectures were highly rated by candidates in spite of the few challenges encountered by combining service provision with learning activity. Physicians highlighted some patients’ concerns about the use of telemedicine and EMRs during clinical consultations. Results from this study confirmed the suitability of ICT use in postgraduate training in family medicine and in service provision.

Significance Emerging insecticide resistance in malaria vectors could presage a catastrophic rebound in malaria morbidity and mortality. In areas of moderate levels of resistance to pyrethroids, long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) with a carbamate insecticide were significantly more effective than IRS with pyrethroid insecticide. The impact on the effectiveness of LLINs could not be quantified. The incremental cost of using a carbamate insecticide to which vectors are susceptible was US $0.65 per person protected per year, which is considered acceptable by international standards. While the WHO recommends that different interventions, where possible, should use different insecticide classes, these data alone should not be used as the basis for a policy change in vector control interventions., Insecticide-based interventions have contributed to ∼78% of the reduction in the malaria burden in sub-Saharan Africa since 2000. Insecticide resistance in malaria vectors could presage a catastrophic rebound in disease incidence and mortality. A major impediment to the implementation of insecticide resistance management strategies is that evidence of the impact of resistance on malaria disease burden is limited. A cluster randomized trial was conducted in Sudan with pyrethroid-resistant and carbamate-susceptible malaria vectors. Clusters were randomly allocated to receive either long-lasting insecticidal nets (LLINs) alone or LLINs in combination with indoor residual spraying (IRS) with a pyrethroid (deltamethrin) insecticide in the first year and a carbamate (bendiocarb) insecticide in the two subsequent years. Malaria incidence was monitored for 3 y through active case detection in cohorts of children aged 1 to

Insecticide-based interventions have contributed to ∼78% of the reduction in the malaria burden in sub-Saharan Africa since 2000. Insecticide resistance in malaria vectors could presage a catastrophic rebound in disease incidence and mortality. A major impediment to the implementation of insecticide resistance management strategies is that evidence of the impact of resistance on malaria disease burden is limited. A cluster randomized trial was conducted in Sudan with pyrethroid-resistant and carbamate-susceptible malaria vectors. Clusters were randomly allocated to receive either long-lasting insecticidal nets (LLINs) alone or LLINs in combination with indoor residual spraying (IRS) with a pyrethroid (deltamethrin) insecticide in the first year and a carbamate (bendiocarb) insecticide in the two subsequent years. Malaria incidence was monitored for 3 y through active case detection in cohorts of children aged 1 to

Many postgraduate family medicine training programmes have been developed to meet the worldwide dire need for practicing family physicians. This study was conducted in Gezira state of Sudan in a “before-and-after” design in the period of 2010–2012 with the aim to assess improvements in candidates’ confidence in performing certain clinical skills. A self-evaluation questionnaire was used with a five-grade scale (1–5) to assess candidates’ confidence in performing 46 clinical skills. A group of 108 participants responded for both the “before” and the “after” questionnaire: the response rate was 91% (before) and 90% (after). In general, a positive progress trend was detected. The mean skill value for all skills was 3.23 (before) and 3.93 (after) with a mean increase of 21.7% (P<0.001). Male students scored constantly higher than females both before and after completing the master’s programme, while females showed a higher percentage in progress. Scores in certain medical disciplines were higher than others. However, disciplines with low scores in the beginning, such as psychiatry and ophthalmology, showed the highest progress percentage. The results show a significant increase in confidence in performing procedural skills designed in the curriculum of the GFMP master’s programme.

In 2004, Sudan adopted artesunate + sulfadoxine/pyrimethamine (SP) combination as the first-line drug, in response to the high level of falciparum resistance to antimalarials. In 2007, a molecular study on antimalarial resistance linked genes, pfcrt, pfmdr1, pfdhfr, pfdhps, and pfATPase6, was conducted on 198 isolates from central and eastern Sudan. We observed a high frequency of point mutations at almost all loci analyzed, mainly of pfcrt 76T (72.7%), pfdhfr 51I (75.3%), and pfdhfr 108N (72.7%) alleles. The MARK III in vitro test for chloroquine sensitivity in 45 P. falciparum isolates showed that 37.8% of the isolates were low resistant and 6.7% were fully resistant. This study represents the most recent molecular investigation on antimalarial resistance in this area after the adoption of artemisinin-based combination therapy (ACT), and underlines the importance of the analysis of SP resistance evolution to monitor the efficacy of ACT therapy in endemic areas.

This indicator-based study assessed the antimalarial drug prescribing and dispensing prac- tices of health care providers in health centres of Khartoum state, and compared these with national guidelines for malaria treatment. A total of 720 patients and their prescriptions in 24 health centres were included. Prescribers adhered to national treatment guidelines for only 278 (38.6%) of patients. Although all were treated for malaria, only 77.6% patients had fever or history of fever and only 64.6% had fever and positive blood films. More than 90% of prescriptions prescribed antimalarial drugs by generic names but dosage forms were correctly written in only 23.5%. There was a high rate of prescribing antimalarial injections. Only half the patients had adequate knowledge of their treatment.

We assessed end-user practice for numerous procedural steps of two types of RDTs: Core Malaria Pf (the cassette format) and OptiMAL IT (the dipstick format). Two types of errors occurred: generic errors common to both types of test and specific errors caused by the test design and manufacturer's instructions. End-user errors were more frequent with OptiMAL IT than Core Pf tests. To improve malaria diagnosis with rapid tests, users require training and better manufacturer's instructions that take into account local conditions.

Background: Early diagnosis and prompt treatment are the basic elements of malaria control. The mother′s perceptions about the cause of the fever, duration of sickness, accessibility and the anticipated cost of treatment, frequent use of traditional medicine, and judgement of the severity of the fever are the most important determinants for effective treatment of fever in children. Subjects and Methods : This cross-sectional study was conducted in Kassala city, in Eastern Sudan to investigate the caregivers′ care-seeking behaviour related to fever among children < 5 years. Data was collected by trained social workers using a structured questionnaire and was analysed by means of SPSS. Results: Three-hundred fifty housewives were interviewed. The majority (85.7%) had had at least basic education and 244 (69.7%) were full-time housewives. A total of 237 (67.7%) mothers were found to have adequate knowledge about malaria. Malaria was perceived by only 143 (40.9%) of the respondents as a cause of low grade fever and this percentage was almost doubled in the case of high fever. There were similar findings with respect to the selection of treatment sources and the use of antimalarial drugs. High fever urged 319 (91.1%) to seek advice from health workers and 281 (80.3%) to take drugs other than chloroquine. Conclusion: The intensity of fever (low/ high) governed the respondent′s perceived causes of fever, decision about available treatment options and the type of antimalarial drugs they used. Health education programmes should focus on the importance of seeking early advice, compliance with prescribed treatment and awareness and handling of danger signs before presenting at health facility.

The Malaria Policy Advisory Committee to the World Health Organization held its sixth meeting in Geneva, Switzerland from 10 to 12 September 2014. This article provides a summary of the discussions, conclusions and recommendations from that meeting. Meeting sessions covered the following: an update on drug resistance and containment including an assessment on the feasibility of elimination of Plasmodium falciparum malaria in the Greater Mekong Subregion; guidance on the control of residual malaria transmission by behaviourally resistant vectors; progress on the implementation of the Global Plan for Insecticide Resistance Management; updates on the Global Technical Strategy, Global Malaria Action Plan and the Plasmodium vivax technical brief; gaps in current World Health Organization Global Malaria Programme guidance for acceleration to elimination; surveillance, monitoring and evaluation; the updated World Health Organization Guidelines for the Prevention and Treatment of Malaria; Round 5 product testing for rapid diagnostic tests; and Intermittent Preventive Treatment for infants. Policy statements, position statements, and guidelines that arise from the Malaria Policy Advisory Committee meeting conclusions and recommendations will be formally issued and disseminated to World Health Organization Member States by the World Health Organization Global Malaria Programme.

A cross-sectional community-based study was carried out in Khartoum urban area aimed at stratifying the area by risk of malaria transmission. Two thousand households [8092 individuals] were surveyed during the cold, dry and rainy seasons of 2002. Households with screened windows, using bednets or both were 5.0% [95% CI: 4.1-6.0], 10.9% [95% CI: 9.5-12.3] and 1.8% [95% CI: 1.2-2.5] respectively. Access to health services was high. Only 3.8% [95% CI: 2.9-4.7] of households kept antimalarial drugs at home. The parasite rate, spleen rate and fever rate were very low [0.21%, 0.17% and 0.97% respectively]. Overall, people in Greater Bahry suffer a greater burden of malaria than those in Greater Khartoum or Greater Omdurman, with a seasonal pattern of transmission.

Background: In 2004, artemisinin-based combination therapy (ACT) was introduced in Sudan for the treatment of malaria. The role of health care providers working in first-level health care facilities is central for the effective implementation of this revised malaria treatment policy. However, information about their level of ACT knowledge is inadequate. This study sought to describe frontline health care providers’ knowledge about the formulations and dose regimens of nationally recommended ACT in Sudan. Methods: This cross-sectional study took place in Gezira State, Sudan. Data were gathered from five localities comprising forty primary health care facilities. A total of 119 health care providers participated in the study (72 prescribers and 47 dispensers). The primary outcome was the proportion of health care providers who were ACT knowledgeable, a composite indicator of health care providers’ ability to (1) define what combination therapy is; (2) identify the recommended first- and second-line treatments; and (3) correctly state the dose regimens for each. Results: All prescribers and 95.7% (46/47) of dispensers were aware of the new national malaria treatment policy. However, 93.1% (67/72) of prescribers compared to 87.2% (41/47) of dispensers recognized artesunate-sulphadoxine/ pyrimethamine as the recommended first-line treatment in Sudan. Only a small number of prescribers and dispensers (9.4% and 13.6%, respectively) were able to correctly define the meaning of a combination therapy. Overall, only 22% (26/119, 95% CI 14.6-29.4) of health care providers were found to be ACT knowledgeable with no statistically significant difference between prescribers and dispensers. Conclusion: Overall, ACT knowledge among frontline health care providers is very poor. This finding suggests that efforts are needed to improve knowledge of prescribers and dispensers working in first-level health care facilities, perhaps through implementing focused, provider-oriented training programmes. Additionally, a system for regularly monitoring and evaluating the quality of in-service training may be beneficial to ensure its responsiveness to the needs of the target health care providers.

Background: In 2010 the Gezira Family Medicine Project (GFMP) was initiated in Gezira state, Sudan, designed as an in-service training model. The project is a collaboration project between the University of Gezira, which aims to provide a 2-year master’s programme in family medicine for practicing doctors, and the Ministry of Health, which facilitates service provision and funds the training programme. This paper presents the programme, the teaching environment, and the first batch of candidates enrolled. Methods: In this study a self-administered questionnaire was used to collect baseline data at the start of the project from doctors who joined the programme. A checklist was also used to assess the health centres where they work. A total of 188 out of 207 doctors responded (91%), while data were gathered from all 158 health centres (100%) staffed by the programme candidates. Results: The Gezira model of in-service family medicine training has succeeded in recruiting 207 candidates in its first batch, providing health services in 158 centres, of which 84 had never been served by a doctor before. The curriculum is community oriented. The mean age of doctors was 32.5 years, 57% were males, and 32% were graduates from the University of Gezira. Respondents stated high confidence in practicing some skills such as asthma management and post-abortion uterine evacuation. They were least confident in other skills such as managing depression or inserting an intrauterine device. The majority of health centres was poorly equipped for management of noncommunicable diseases, as only 10% had an electrocardiography machine (ECG), 5% had spirometer, and 1% had a defibrillator. Conclusions: The Gezira model has responded to local health system needs. Use of modern information and communication technology is used to facilitate both health service provision and training. The GFMP represents an example of a large-volume scaling-up programme of family medicine in Africa. publishedVersion

Purpose: To develop effective measures of reducing the proportion of severe malaria presentation and deaths attributed to malaria, an adequate understanding of beliefs and practices in households and at the level of primary health care is necessary. The objectives of this paper are to explore beliefs and practices related to the management of severe malaria, and to identify barriers to early consultation. Subjects and Methods: A cross-sectional hospital-based study was conducted in five hospitals in Sudan in 2003. All malaria cases admitted, or their care givers were interviewed by a medical doctor using pre-coded and pre-tested questionnaire. Results: Enrolled in this study, were a total of 482 patients, 62.9% of whom were female. Almost 75.0% of the respondents perceived that malaria had serious complications. Anaemia as a complication was mentioned by 115 (32.0%) respondents. A total of 418 (86.7%) patients sought advice from health personnel. Of these, 305 (73.0%) did so more than 24 hours after the onset of the illness. Distance, lack of money, unavailability of transportation or all were the reasons mentioned as barriers to seeking care at hospitals. More than 70.0% of the patients received anti-malarial drugs before admission with a clear preference for the injectable form of chloroquine. Multivariate analysis revealed that “cost of services” and “not seeking help from health personnel” were the determinants for late consultation. Conclusion: The study revealed that late consultation was a feature in many parts of Sudan. Among the barriers mentioned by the respondents, the cost of services was of the greatest concern.

Malaria is endemic all over Sudan. The population are at risk of malaria infection to variable degrees. Kidney-transplanted patients on maintenance immunosuppressive therapy are known to be prone to infection, but there is not enough data in the medical literature as to whether they are more susceptible to malaria infection in endemic areas. This study was conducted in the Gezira Hospital for Renal Diseases and Surgery to assess the effect of maintenance immunosuppressive therapy in renal transplantation on malaria incidence. A total of 110 individuals were enrolled: 55 were renal-transplanted patients with end-stage renal disease who received kidney transplantation at least one year earlier and were on maintenance immunosuppressive medications. The other 55 individuals were the compatible healthy group. Thorough follow-up was exercised for both groups for one year (January-December 2009). Following the World Health Organization criteria for malaria diagnosis, a total of 51 malarial attacks were reported in both the groups, 25 in the transplanted group and 26 in the controls. The incidence difference between both groups was statistically insignificant [0.76 (± 1.170) and 1.09 (± 1.917) P = 0.282 among transplanted group and control group, respectively]. Providing routine malaria prophylaxis is not required for renal transplant recipients on maintenance immunosuppressive.

Background Malaria remains a major public health problem especially in sub-Saharan Africa. Despite the efforts exerted to provide effective anti-malarial drugs, still some communities suffer from getting access to these services due to many barriers. This research aimed to assess the feasibility and acceptability of home-based management of malaria (HMM) strategy using artemisinin-based combination therapy (ACT) for treatment and rapid diagnostic test (RDT) for diagnosis. Methods This is a study conducted in 20 villages in Um Adara area, South Kordofan state, Sudan. Two-thirds (66%) of the study community were seeking treatment from heath facilities, which were more than 5 km far from their villages with marked inaccessibility during rainy season. Volunteers (one per village) were trained on using RDTs for diagnosis and artesunate plus sulphadoxine-pyrimethamine for treating malaria patients, as well as referral of severe and non-malaria cases. A system for supply and monitoring was established based on the rural health centre, which acted as a link between the volunteers and the health system. Advocacy for the policy was done through different tools. Volunteers worked on non-monetary incentives but only a consultation fee of One Sudanese Pound (equivalent to US$0.5). Pre- and post-intervention assessment was done using household survey, focus group discussion with the community leaders, structured interview with the volunteers, and records and reports analysis. Results and discussion The overall adherence of volunteers to the project protocol in treating and referring cases was accepted that was only one of the 20 volunteers did not comply with the study guidelines. Although the use of RDTs seemed to have improved the level of accuracy and trust in the diagnosis, 30% of volunteers did not rely on the negative RDT results when treating fever cases. Almost all (94.7%) the volunteers felt that they were satisfied with the spiritual outcome of their new tasks. As well, volunteers have initiated advocacy campaigns supported by their village health committees which were found to have a positive role to play in the project that proved their acceptability of the HMM design. The planned system for supply was found to be effective. The project was found to improve the accessibility to ACTs from 25% to 64.7% and the treatment seeking behaviour from 83.3% to 100% before- and after the HMM implementation respectivly. Conclusion The evaluation of the project identified the feasibility of the planned model in Sudan's condition. Moreover, the communities as well as the volunteers found to be satisfied with and supportive to the system and the outcome. The problem of treating other febrile cases when diagnosis is not malaria and other non-fever cases needs to be addressed as well.

Background In order to assess the effectiveness of long-lasting insecticide-treated nets (LLINs) as a method for malaria control, there is a need to determine how high is the retention of bed nets, how they are utilized, and how efficacious they are against the mosquitoes that transmit the disease. This is especially important in case of Sudan after emergence of resistance to pyrethroids in use. Methods This two-step study aimed to assess the retention and efficacy of LLINs (Olyset™) distributed in the year 2006 in Kassala district in eastern Sudan. In the first step, using a cluster sample technique, heads of 210 households (30 by 7) were interviewed, and six LLINs were collected and later tested for efficacy. In the second step, eight focus group discussion sessions were conducted to complement the results from the first step. Results Results showed that the retention of LLINs was 92.9% one-and-half years after distribution. Some bed nets were distributed against a price. Utilization of bed nets by children under five years of age and by pregnant women was found to be 55% and 42.1% respectively. For the bioassay efficacy tests, mean knock down after 60 minutes was 91.1%, while mortality after 24 hours was 99.4%. Conclusion LLINs (Olyset™) were efficacious at the time of the study. People appreciated the usefulness but were not fully aware of their importance and were not motivated enough to use them. The retention of the bed nets was quite high but the utilization of the nets needs more focus from the National Malaria Control Programme. Bed net distribution activities should be accompanied by wide health education campaigns and followed up with tracking surveys to evaluate their effectiveness.

Background In Sudan, chloroquine (CQ) remains the most frequently used drug for falciparum malaria for more than 40 years. The change to artemisinin-based combination therapy (ACT) was initiated in 2004 using the co-blister of artesunate + sulfadoxine/pyrimethamine (AS+SP) and artemether + lumefantrine (ART+LUM), as first- and second-line, respectively. This article describes the evidence-base, the process for policy change and it reflects the experience of one year implementation. Relevant published and unpublished documents were reviewed. Data and information obtained were compiled into a structured format. Case description Sudan has used evidence to update its malaria treatment to ACTs. The country moved without interim period and proceeded with country-wide implementation instead of a phased introduction of the new policy. The involvement of care providers and key stakeholders in a form of a technical advisory committee is considered the key issue in the process. Development and distribution of guidelines, training of care providers, communication to the public and provision of drugs were given great consideration. To ensure presence of high quality drugs, a system for post-marketing drugs surveillance was established. Currently, ACTs are chargeable and chiefly available in urban areas. With the input from the Global Fund to fight AIDs, Tuberculosis and Malaria, AS+SP is now available free of charge in 10 states. Conclusion Implementation of the new policy is affected by the limited availability of the drugs, their high cost and limited pre-qualified manufacturers. Substantial funding needs to be mobilized by all partners to increase patients' access for this life-saving intervention.