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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 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 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.

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).

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 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.

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

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.

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.

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

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.

Summary The factors that identify patients at risk of malaria treatment failure were evaluated in an area of unstable malaria transmission in eastern Sudan. We analyzed data from 471 patients who had been enrolled in six previous clinical antimalarial trials for uncomplicated Plasmodium falciparum malaria. Thirty-four (7.3%) had treatment failure (crude). In logistic regression models, an age of ≤5 years (odds ratio [OR] = 3.7; 95% CI 1.5–8.6; P = 0.002) and parasitaemia that took 3 days to clear (OR = 2.4; 95% CI 1.0–5.9; P = 0.04) were found to be predictors for treatment failure. Presenting temperature (OR = 1.4; 95% CI 0.9–2.2; P = 0.1), level of parasitaemia (OR = 1.0; 95% CI 1.0–1.0; P = 0.8) and presence of gametocytes (OR = 0.3; 95% CI 0.9–1.2; P = 0.1) were not associated with treatment failure. Thus, these factors might be used to identify those in whom treatment might fail in the future.

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.

Background In order to optimally prioritize and use public and private budgets for equitable malaria vector control, there is a need to determine the level and determinants of consumer demand for different vector control tools. Objectives To determine the demand from people of different socio-economic groups for indoor residual house-spraying (IRHS), insecticide-treated nets (ITNs), larviciding with chemicals (LWC), and space spraying/fogging (SS) and the disease control implications of the result. Methods Ratings and levels of willingness-to-pay (WTP) for the vector control tools were determined using a random cross-sectional sample of 720 householdes drawn from two states. WTP was elicited using the bidding game. An asset-based socio-economic status (SES) index was used to explore whether WTP was related to SES of the respondents. Results IRHS received the highest proportion of highest preferred rating (41.0%) followed by ITNs (23.1%). However, ITNs had the highest mean WTP followed by IRHS, while LWC had the least. The regression analysis showed that SES was positively and statistically significantly related to WTP across the four vector control tools and that the respondents' rating of IRHS and ITNs significantly explained their levels of WTP for the two tools. Conclusion People were willing to pay for all the vector-control tools, but the demand for the vector control tools was related to the SES of the respondents. Hence, it is vital that there are public policies and financing mechanisms to ensure equitable provision and utilisation of vector control tools, as well as protecting the poor from cost-sharing arrangements.

OBJECTIVES: To determine levels of socioeconomic inequities in the prevention of malaria, and to examine the implications of the findings for improving the equitable control of malaria in the Sudan. METHODS: A cross-sectional survey using a pre-tested interviewer-administered questionnaire was administered to 720 randomly selected householders from six localities in Gezira and Khartoum States. A socioeconomic status (SES) index, which was developed using principal components analysis, was used to examine socioeconomic inequity in the prevention of malaria. FINDINGS: Socioeconomic status was positively related to expenditures and use of vector control tools. The poorest households spent the least amounts of money to prevent malaria and were the least likely to own mosquito nets. CONCLUSION: The inequity in the prevention of malaria in the study areas has to be redressed before malaria can be effectively controlled in Sudan. Malaria control managers should continually determine the extent to which malaria preventive tools reach the poorest socioeconomic groups, and fashion strategies that will ensure that equity is always maintained.

Background Early diagnosis and effective treatment with an appropriate drug form the main components of the World Health Organization's strategy to reduce malaria related mortality. The few available drugs might be safeguarded if combined with artesunate. The addition of artesunate to a standard antimalarial treatment substantially reduces treatment failure, recrudescence and gametocyte carriage. Methods During late 2004, the efficacy of artesunate (4 mg/kg. day, on days 0–2) plus sulfadoxine-pyrimethamine (25 mg/kg, on day 0) for the treatment of uncomplicated Plasmodium falciparum malaria was investigated in four sentinel areas in Sudan, with different malaria transmission (Damazin, Kassala, Kosti, and Malakal). Results Two hundreds and sixty-nine patients completed the 28-day follow-up. On day one, 60 (22.3%) patients were febrile and 15 (5.5%) patients were parasitaemic. On day three, all the patients were afebrile and aparasitaemic. While two patients (0.7%, Kassala) showed late Clinical and Parasitological Failures, the rest (99.3%) of the patients demonstrated Adequate Clinical and Parasitological Response. A gametocytaemia were detected during the follow-up in one patient (0.37%, Kassala). Adverse drug effects were detected in 32 (11.9%) patients Conclusion The study showed that AS plus SP is an effective, safe drug in the treatment of uncomplicated P. falciparum malaria in Sudan.

Objective To determine the prevalence of intestinal parasitic infections and soil-transmitted helminths (STHs) among primary schoolchildren in El dhayga, Central Sudan. Methods In this cross-sectional study, three fresh faecal samples were collected from each child, which were examined by direct wet mount, brine flotation, formalin–ether and Kato–Katz techniques. The intensity of each STH infection was expressed as the mean of eggs per gram counts of the three samples. Results In total, 142 (90.4%) of 157 children harboured at least one type of intestinal parasite. Ascaris lumbricoides, Hymenolepis nana, Entamoeba histolytica and Giardia lamblia were the most common parasites found, with prevalence rates of 32.5%, 30.6%, 33.1% and 19.7%, respectively. Out of these 157 children, 29 (18.5%) harboured more than two intestinal parasitic infections. No cases of Schistosoma mansoni or Enterobius vermicularis were identified. Conclusions The study demonstrates significant burden of intestinal protozoa and STH infections in this part of Sudan and highlights the need for preventive and intervention measures.

Background Effective management of malaria in children under the age of 5 requires mothers to seek, obtain, and use medication appropriately. This is linked to timely decision, accessibility, correct use of the drugs and follow-up. The aim of the study is to identify the basis on which fever was recognized and classified and exploring factors involved in selection of different treatment options. Methods Data was obtained by interviewing 96 mothers who had brought their febrile children to selected health facilities, conduction of 10 focus group discussions with mothers at village level as well as by observation. Results A high score of mothers' knowledge and recognition of fever/malaria was recorded. Mothers usually start care at home and, within an average of three days, they shift to health workers if there was no response. The main health-seeking behaviour is to consult the nearest health facility or health personnel together with using traditional medicine or herbs. There are also health workers who visit patients at home. The majority of mothers with febrile children reported taking drugs before visiting a health facility. The choice between the available options determined by the availability of health facilities, user fees, satisfaction with services, difficulty to reach the facilities and believe in traditional medicine. Conclusion Mothers usually go through different treatment option before consulting health facilities ending with obvious delay in seeking care. As early effective treatment is the main theme of the control programme, implementation of malaria home management strategy is urgently needed to improve the ongoing practice.

Background Malaria is the leading cause of morbidity and mortality in Sudan. The entire population is at risk of contracting malaria to different levels. This study aimed to assess the effectiveness of communication for behavioural impact (COMBI) strategy in enhancing the utilization of long-lasting insecticidal nets (LLINs) among mothers of under-five children in rural areas. Methods A randomized community trial was conducted in rural area of Kosti locality, White Nile State, Sudan, among mothers of under-five children, from January 2013 to February 2014. A total of 761 mothers from 12 villages were randomly selected, 412 mothers from intervention villages and 349 were from comparison villages. Results The knowledge of mothers, in intervention villages, about malaria vector, personal protective measures (PPM) against malaria, and efficacy of LLINs was significantly increased from 86.9 to 97.3 %; 45.9 to 92 % and 77.7 to 96.1 % respectively. Knowledge about usefulness of PPM, types of mosquito nets and efficacy of LLINs was significantly higher in intervention villages compared to comparison villages (p

Background The World Health Organization (WHO) recommends artemisinin-based combination therapies (ACTs) as first-line treatment for uncomplicated malaria. Sudan revised its malaria treatment policy accordingly in 2004. However, eight years after ACTs were introduced in Sudan the patterns of ACT prescribing practices among health care providers remain unclear. We systematically analyzed use of ACTs in a large number of primary health facilities and we discuss the public health implications of our findings. Methods This cross-sectional study was based on WHO’s guidance for investigating drug use in health facilities. Data were collected from 40 randomly selected primary health centers in five localities in Gezira State, Sudan. The primary outcome of the study was the proportion of patients who were adequately managed according to Sudan’s recommended malaria treatment guidelines. Twelve drug-use indicators were used to assess key ACT prescribing practices. Results One thousand and two hundred patients diagnosed with uncomplicated malaria were recruited into the study. ACT was prescribed for 88.6%patients and artemether injections were (incorrectly) prescribed in 9.5% of cases. Only 40.9% of patients in the study were correctly diagnosed and 26.9% were adequately managed according to the nationally recommended treatment guidelines. Incorrect prescribing activities included failure to use generic medicine names (88.2%), incorrect dosage (27.7%), and unexplained antibiotic co-prescription (24.2%). Dispensing practices were also poor, with labeling practices inadequate (97.1%) and insufficient information given to patients about their prescribed treatment (50.5%). Conclusion Irrational malaria treatment practices are common in Sudan. This has important public health implications since failure to adhere to nationally recommended guidelines could play a role in the future development of drug resistance. As such, identifying ways to improve the anti-malarial prescribing practices of heath workers in Sudan may be a priority.

Background In spite of the World Health Organization recommendations for the treatment of malaria, febrile patients are still infrequently tested and erroneously treated for malaria. This study aimed to investigate the adherence to malaria national protocol for the management of malaria among under five years old children. Methods A cross sectional hospital-based study was conducted during the period from September through December 2013 among febrile children below the age of five years attending the outpatient department of Omdurman Children Hospital, Sudan. Demographic, clinical and laboratory data [blood film, rapid diagnostic test (RDTs), haemoglobin, WBCs and chest X ray] and anti-malarials and/or antibiotics prescription were recorded. Results A total of 749 febrile children were enrolled. The mean (SD) age was 37.51 (41.6) months. Less than a half, (327, 43.7%) of children were investigated for malaria using microscopy (271, 82.9%), RDT (4, 1.2%) or both (52, 15.9%). Malaria was not investigated for more than a half, (422, 56.3%) however investigations targeting other causes of fever were requested for them. Malaria was positive in 72 (22%) of the 327 investigated children. Five (1.6%) out of 255 with negative malaria tests were treated by an anti-malarials. Quinine was the most frequently prescribed anti-malarials (65, 72.2%) then artemisinin-based combination therapy (ACT) (2, 27.8%). The majority of the 749 children (655, 87.4%) were prescribed an antibiotic. Conclusion There is a poor adherence to malaria management protocol in Sudan among physicians treating children below five years of age. There was a high rate of antibiotic prescription needs.

Background Estimating the burden of malaria in Sudan is important for evidence-based planning of malaria control. Estimates of malaria burden in terms of DALYs (Disability Adjusted Life Years) were not developed locally. This study synthesized information from different sources to calculate malaria incidence, mortality and DALYs lost in Sudan in 2002. Methods A search for local studies and reports providing epidemiological data on malaria in Sudan was conducted. Preliminary estimates of incidence rate, case fatality rate and mortality rate were developed from the data found. The preliminary estimates were processed in the disease modelling computer software, DisMod II, to produce internally consistent mortality and incidence rates, which were used to calculate DALYs lost due to malaria. Results Malaria incidence in Sudan was estimated to be about 9 million episodes in 2002 and the number of deaths due to malaria was about 44,000. 2,877,000 DALYs were lost in Sudan in 2002 due to malaria mortality, episodes, anaemia and neurological sequelae. Children under five years of age had the highest burden. Males had the highest incidence and mortality, but females lost more DALYs. Conclusion Formal health system data underestimated malaria burden. The burden estimates can be useful in informing decision making, although uncertainty around them needs to be quantified. Epidemiological research is needed to fill data gaps and update the estimates.

BackgroundThe epidemiology of fevers and their management in areas of low malaria transmission in Africa is not well understood. The characteristics of fever, its treatment and association with infection prevalence from a national household sample survey in the northern states of Sudan, an area that represents historically low parasite prevalence, are examined in this study.MethodsIn October-November 2009, a cluster sample cross-sectional household malaria indicator survey was undertaken in the 15 northern states of the Sudan. Data on household assets and individual level information on age, sex, whether the individual had a fever in the last 14 days and on the day of survey, actions taken to treat the fever including diagnostic services and drugs used and their sources were collected. Consenting household members were asked to provide a finger-prick blood sample and examined for malaria parasitaemia using a rapid diagnostic test (RDT). All proportions and odds ratios were weighted and adjusted for clustering.ResultsOf 26,471 respondents 19% (n = 5,299) reported a history of fever within the last two weeks prior to the survey and 8% had fever on the day of the survey. Only 39% (n = 2,035) of individuals with fever in last two weeks took any action, of which 43% (n = 875) were treated with anti-malarials. About 44% (n = 382) of malaria treatments were done using the nationally recommended first-line therapy artesunate+sulphadoxine-pryrimethamine (AS+SP) and 13% (n = 122) with non-recommended chloroquine or SP. Importantly 33.9% (n = 296) of all malaria treatments included artemether monotherapy, which is internationally banned for the treatment of uncomplicated malaria. About 53% of fevers had some form of parasitological diagnosis before treatment. On the day of survey, 21,988 individuals provided a finger-prick blood sample and only 1.8% were found positive forPlasmodium falciparum. Infection prevalence was higher among individuals who had fever in the last two weeks (OR = 3.4; 95%CI = 2.6 - 4.4, p < 0.001) or reported fever on the day of survey (OR = 6.2; 95%CI = 4.4 - 8.7, p < 0.001) compared to those without a history of fever.ConclusionAcross the northern states of the Sudan, the period prevalence of fever is low. The proportion of fevers that are likely to be malaria is very low. Consequently, parasitological diagnosis of all fevers before treatment is an appropriate strategy for malaria case-management. Improved regulation and supervision of health workers is required to increase the use of diagnostics and remove the practice of prescribing artemisinin monotherapy.