Typhoid Fever in : Some Geographic and Time Considerations from 2000 through 2008

Samir M. A. Hassan Alredaisy Department of Geography, Faculty of Education, University of , Khartoum,

P.O.Box 406, Omdurman, Sudan Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021

Typhoid is used worldwide as an indicator of the de mauvaises conditions hygièniques. Cet article level of public health, since it is caused mainly décrit les tendances spatiales et temporelles de by unhygienic conditions. This article describes la présence de la typhoïde dans le Soudan geographic and temporal trends of typhoid in septentrional comme une indication du niveau northern Sudan as indicative of the level of d’hygiène communautaire entre 2000 et 2008, en community hygiene from 2000 to 2008, based on se basant sur des statistiques officielles publiées official governmental statistics published in en 2009–2010. Le Soudan méridional en est 2009–10. Southern Sudan is excluded for this exclu par manque de données. Les principaux period because of lack of data. The main find- résultats montrent que la fréquence de la ings show that typhoid has a general fluctuating typhoïde fluctue dans le temps, mais que les taux pattern, while three-year prevalence rates depict de prevalence sur trois ans signalent une a steady increase. Regional differences by three- augmentation régulière. Les différences year prevalence rates are remarkable between régionales de ces taux de prevalence sont the central region, including Khartoum and remarquables si l’on compare la région centrale , and other regions of Sudan; these differ- (qui comprend les régions de Khartoum et de ences are statistically significant at all signifi- Gezira) aux autres régions du Soudan ; ces cance levels. Geographic proximity is influential différences sont statistiquement signifiantes à in the distribution of typhoid within Sudan’s tous les niveaux. La proximité géographique states. The three-year prevalence rates distin- influence la distribution de la typhoïde dans les guished two major groups of spatial distribution différentes divisions administratives du pays. of typhoid by state. The first group shows a Pour les taux de prevalence sur trois ans, on peut continuous increase in typhoid and includes distinguer deux groupes principaux de régions central and western Sudan; the second group en fonction de distribution spatiale de la fièvre : consists of two separated pockets of a fluctuating le premier groupe montre une augmentation pattern of typhoid in eastern and western Sudan. continue de cette maladie et comprend le Soudan Proportional change by state before the base central et occidental ; le second groupe consiste year of 2004 shows a lower percentage relative en deux poches de fluctuations séparées: l’une to the period 2005–8, with few exceptions. Rank au Soudan occidental et l’autre au Soudan correlation between percent change in popula- oriental. Les changements proportionnels par tion and percent change in typhoid by state is région avant la date de référence de 2004 weak at 0.01. The author proposes the “ESEN- montrent un pourcentage moins élevé pour la GEO” model to assess and reduce typhoid in période 2005–2008, avec peu d’exceptions. La Sudan. corrélation entre le pourcentage de la crois- sance démographique et le pourcentage de l’évo- Key words: typhoid, contamination, immuniza- lution de la typhoïde par région est faible (0.01). tion, administrative states, education, society, L’auteur introduit le modèle « Esengeo »pour geographic proximity, northern Sudan évaluer et ainsi contribuer à réduire la typhoïde au Soudan.

La fièvre typhoïde est utilisée dans le monde Mots-clés : typhoïde, contamination, immunisa- entier comme un indicateur du niveau de santé tion, régions administratives, éducation, société, publique, car elle est principalement causée par proximité géographique, Soudan septentrional-

The Arab World Geographer/Le Géographe du monde arabe Vol 12, No 3-4 (2009) 173–187 © 2009 by AWG Publishing, Toronto, Canada 174 Samir M. A. Hassan Alredaisy

Introduction cent. A chronic carrier is defined as a person whose stool is continuously positive for S. Typhoid enteric fever is a waterborne typhi for at least a year following an episode disease transmitted via the faecal–oral route of the disease; a person with positive stool and is contracted by the consumption of cultures but without any history of the disease water and foodstuffs contaminated with can spread infection to others or cause Salmonella typhi or typhoid bacillus or by contamination. Chronic carriers are a threat urine from an infected person or carrier to the community around them (Sonhani et al. (Royal Tropical Institute 2010). It can live 1998). Middle-aged women are common Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 and multiply in the gallbladders of carriers carriers because they care for others, such as whose health it does not affect; it can survive household members or young children, who in water for 7 days, in sewage for 14 days, may be infected persons or carriers. and in ice cream for 1 month. It is destroyed The prevalence of typhoid fever is deter- by temperatures above 50°C (Punjani and mined largely by hygienic standards and prac- Bhatia 1997). The incubation period ranges tices among individuals and communities and from 8 to 28 days, depending on whether or has been used as an indicator of the level of not the host has been vaccinated and, if so, community hygiene. Typhoid is an interna- on the inoculum size and immune status tionally as well as locally notifiable disease (i.e., vaccination coverage) of the host. because of its epidemic potential (WHO Transmission can also occur directly within 1997); infection with S. typhi causes an esti- a family through contact with a patient or a mated 20 million cases of typhoid fever and chronic carrier. Indirectly, improperly 200 000 deaths worldwide each year washed fruits and vegetables, if consumed (PhysOrg.com 2009). raw, can also transmit the bacillus. About Typhoid has been affecting people from 90 % of cases are transmitted indirectly time immemorial, without being identified as (Lucas and Gilles 2003). Flies act as passive a separate illness because its symptoms vectors via fluid contacts with their legs resemble those of malaria, typhus, and dysen- when they feed in both latrines and kitchens. tery. It is difficult to establish a historical Typhoid is recognized by the sudden onset of diagnosis prior to the identification of the sustained fever, severe headache, nausea, disease by William Wood Gerhard in 1836, by and severe loss of appetite; it is sometimes A. P. Stewart in 1840, and lastly by William accompanied by a hoarse cough and consti- Jenner in 1851 (the first to successfully pation or diarrhea. Because its symptoms define typhoid fever). However, scholars resemble those of malaria, typhus, and other working on the history of Jamestown, enteric diseases, typhoid was not recognized Virginia, believe that a typhoid outbreak was until relatively recently. responsible for the deaths of more than 6 000 Humans are the only known reservoir of settlers between 1607 and 1624. During the infection. Infection may take the form of an war against South Africa in the late 19th overt case of the disease, an ambulatory century, British troops lost 13 000 men to “missed” case, or an asymptomatic carrier. typhoid, as compared to 8 000 deaths in battle About 2–4 % of patients treated become (WHO 1997). It appears that the incidence chronic carriers of the disease, and in most may still be as high today as it was in the past; parts of the world faecal carriers are more however, today the fatality rate has dropped common than urinary carriers. The carrier dramatically. In January 2010, it was reported state is more common among persons that the typhoid outbreak in Gabon had infected during middle age, especially spread to the capital, Libreville, which had women (Lucas and Gilles 2003; Bensenson been grappling with water shortages for two 1975). Carriers are either chronic or convales- weeks (IRIN 2010). In many parts of Kenya,

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FIGURE 1 ESENGEO model for typhoid assessment and reduction in Sudan typhoid fever is prevalent, especially in 100 000 children aged 4–5 years old Nyanza and Eastern provinces, where (Quaicoe-Duho 2009). poverty, congestion, and unhygienic living In Ochiai et al.’s (2003) study of 5 Asian conditions have worsened the situation. countries, a total of 21 874 episodes of fever Nyanza, for example, is typhoid-ridden were detected. The annual typhoid incidence because of a lack of treated water combined (per 100 000 person-years) in the 5–15 age with residents’ ignoring precautionary and group varied substantially among sites: it was preventive measures (Onyango 2002). In found to be high in India and Pakistan, inter- 2002, an outbreak of typhoid struck the mediate in Indonesia, and low in China and Jirgital District in the Rasht Valley of Vietnam (Ochiai et al. 2003). Here the rela- Tajikistan; a latrine-contaminated water tionship between mother and child is impor- source was the suspected source of the tant: a child’s long-term exposure to its outbreak (Médicins sans frontières 2002). In mother, who may be infected or a carrier, 2003, Crump et al. estimated that the inci- transmits typhoid. This is particularly the case dence of typhoid fever was 13 per 100 000 when mothers are fully responsible for chil- persons per year in Bilbeis District, Egypt. drearing. “These findings highlight the In virtually all areas where typhoid fever considerable, but geographically heteroge- is endemic, incidence is highest in children 5– neous, burden of typhoid fever in endemic 19 years of age. Data mainly from Africa, areas of Asia, and underscore the importance Asia, and Latin America show that typhoid of evidence on disease burden in making fever continues to be a public-health problem, policy decisions about interventions to with schoolchildren aged between 5 and 15 control this disease” (Ochiai et al. 2003, 260). disproportionately affected. In some endemic The Ministry of Health Statistics in areas, children under age five show incidence Sudan reports that the primary risk factors for rates similar to or exceeding those of school- typhoid are physical conditions (e.g., climate aged children. In Ghana’s Ashanti region, the conducive to insect breeding), population estimated incidence of typhoid is 205 per factors (e.g., overcrowding, migration),

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TABLE 1 Population, typhoid patients treated, and calculated prevalence rate in northern Sudan, 2000– 2008 Year Population Patients treated Prevalence rate 2000 26 046 000 16 035 0.6 2001 26 840 000 18 865 0.7 2002 27 569 000 21 679 0.8

2003 28 363 000 25 166 0.8 Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 2004 29 146 000 38 786 1.1 2005 29 949 000 48 053 1.3 2006 30 767 000 66 436 2.1 2007 31 623 000 77 480 2.0 2008 30 894 000 89 473 2.9 Average 29 021 000 44 663 1.4 Source: Prevalence rates calculated by author from annual health statistics reports for 2000–2008, Ministry of Health, Sudan. illiteracy, inadequate water supply, and low educational, societal, environmental, and government expenditure in the health sector. geographical information on typhoid; the The purpose of this study is to highlight processes are the impacts of these inputs on geographic and temporal variations of typhoid in a community; and the outputs are typhoid in Sudan from 2000 through 2008. the assessment and reduction of typhoid. The study proposes the “ESENGEO” Education is important in the assessment (Education, Society, Environment, Geo- and reduction of typhoid. An educated society graphy) model (see Figure 1) to address will, of course, have knowledge about personal sources of infection and modes of transmis- hygiene, environmental sanitation, typhoid sion of typhoid. The ESENGEO model shows transmission, and infection. Health education sources of infection of typhoid as including will create awareness of the disease and ways lack of hygienic standards; inappropriate of avoiding infection. Traditional knowledge individual and community health practices; about infection and curing of diseases is bene- and infected persons, carriers, and reservoirs. ficial. In addition, social capacity building Similarly, the model depicts direct and indi- through collective work and civil or voluntary rect modes of typhoid transmission, as well as organizations can work to assess and combat the role of flies. The main objective of the typhoid. Typhoid is highly linked with the ESENGEO model is to assess and reduce physical environment—temperature, rainfall, infection and transmission of typhoid in a and flooding or aridity determine its incidence, community. The importance of ESENGEO morbidity, and seasonality and affect the comes from its simplicity, its potential to deal breeding of insects; the need for such data is with the available resources at the grassroots substantial for the assessment and prevention level, and its affordability for use with any of typhoid. Geographical data include infor- infectious disease in any geographic setting. mation on location, population mobility and The components of ESENGEO focus on density, congestion, and geographic proximity reducing the incidence of typhoid (arrows in and the role of these factors in typhoid infec- Figure 1) by addressing sources of infection tion and transmission. Typhoid prevalence and modes of transmission of typhoid. ESEN- rates have geographical scales: the global, the GEO works like an open ecosystem, with continental, the regional, and the national. inputs, processes, and outputs. The inputs are Determination of such geographic differences

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FIGURE 2 Location and in prevalence rates provide a spatial database Official statistics published by the for dealing with typhoid. The application of National Ministry of Health in Sudan were ESENGEO in Sudan will be further outlined used to analyze typhoid space–time behav- following a review of the results of the present iour from 2000 through 2008. The statistics study. were treated at the national, regional, and state levels; regional agglomeration was Data and Methodology carried out by including many administrative states in each of four geographic regions: the Sudan is located in north-east Africa; it is northern, central, eastern, and western bordered by 9 countries and is divided into 16 regions. This regional division follows the states (see Figure 2). The population of northern general mental map held by Sudanese as to Sudan was recorded 30 894 000 in 2008, with an the spatial division of their country. average population of 29 021 000 and annual National and state typhoid prevalence change of 2 % for the period 2000–2008 (see rates were calculated by dividing the number Table 1). This population, distributed by region of patients treated by total population and and by state, constitutes the population under multiplying by 1 000; regional prevalence study in this paper, as illustrated by typhoid rates were calculated by summing the preva- prevalence rates shown in Tables 2 and 3. lence rates for the states within a region and

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TABLE 2 Prevalence of typhoid in Sudan, by region Year Northern region Central region Eastern region Western region 2000 0.6 0.1 0.3 0.01 2001 0.02 0.8 0.03 0.01 2002 0.2 0.8 0.01 0.01 2003 0.4 0.9 0.2 0.07 Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 2004 1.4 1.5 0.3 0.08 2005 1.1 2.6 0.1 0.1 2006 0.9 3.0 1.6 0.1 2007 2.3 3.5 0.4 0.3 2008 2.9 2.2 0.9 0.4 Average 1.1 1.7 0.4 0.1 Rank 2 1 3 4 then taking the average. Time trends for Results typhoid were measured numerically, propor- tionally, and directionally to depict yearly The General Situation of Typhoid in Sudan changes and are presented in graphs. Three- year prevalence rates were also calculated at The number of typhoid patient records in the spatial scales indicated above. An analysis Sudan is successively increasing (see Table of variance (ANOVA) compared three-year 1), with a general annual average of 44 663 prevalence rates of typhoid across major patients. The general behaviour of the disease regions of Sudan to establish significant shows a slow increase between 2000 and differences at the 0.001 level, such that the 2004, a steady increase between 2004 and null hypotheses (that there are no statistically 2007, and a sharp increased up to 2008. The significant differences in three-year typhoid calculated year-by-year percent change in the prevalence rates between regions within number of typhoid patients similarly shows a Sudan) is rejected if the calculated F-value is fluctuating behavioural pattern for the study greater than the critical value. Proportional period. The calculated difference between change of typhoid is shown via index percent change in average annual typhoid numbers by state; actual figures were patients (up 21.9 %) and percent change in converted to percentages by taking the year average annual population (up 2 %) is 2004 as the base year to facilitate comparison extremely high at 19.9 %. The prevalence rate across all figures. Spearman’s rank correla- of typhoid shows a steady increase from 2000 tion between percent change in population through 2005, then fluctuates up to 2008 (see and percent change in typhoid prevalence Table 1). rates by state was calculated as follows: The time behaviour of typhoid was depicted by calculating the three-year preva- lence rate, which smoothed the curve to , where depict a steady increase in the prevalence of typhoid in Sudan (see Figure 3). Thus, is the sum of squares of differences between increasing population is accompanied by population and prevalence rate for each state increasing typhoid, which reflects educa- and n is the number of values. tional, societal, environmental, and geographical situations in the country.

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TABLE 3 Typhoid prevalence rates (PR) and index numbers (IN) for Sudan by state, 2000–2008 Year State 2000 2001 2002 2003 2004 2005 2006 2007 2008 Average Rank Northern PR 0.04 0.05 0.2 0.6 1.9 1.4 1.0 2.5 1.5 1.02 7 IN 2.0 2.8 11.1 33.3 100 77.6 55.5 141.2 86.6 – PR 0.6 n/a 0.2 0.2 0.9 0.8 0.9 2.2 4.3 1.3 4 Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 IN 16.8 0 17.9 23.7 100 85.9 107.9 246.9 530.6 – Khartoum PR 0.3 3.4 3.7 3.7 5.2 5.1 6.7 7.9 4.2 4.5 1 IN 47.1 58.7 66.6 67.9 100 102.5 137.6 170.4 76.1 – Gizira PR 0.3 0.5 0.5 0.9 1.2 2.5 2.3 2.7 3.4 1.6 3 IN 21.6 34.2 41.8 75.1 100 216.3 198.4 237.4 262.4 – PR n/a n/a 0.02 0.1 0.2 0.3 0.1 0.5 1.2 0.3 9 IN 0 0 11.5 39.8 100 206.5 97.3 322.9 821.1 – PR n/a n/a n/a n/a 0.9 5.0 5.1 4.0 0.7 3.1 2 IN 0 0 0 0 100 524.1 549.6 447.7 787.3 – Sinnar PR n/a n/a n/a n/a 0.08 0.3 0.8 2.6 1.7 1.09 5 IN 0 0 0 0 100 388.8 1,049 3,373 2,020 – PR 0.6 .005 0.02 0.3 0.6 0.2 0.1 0.1 0.3 0.24 10 IN 99.3 0.97 4.12 53.4 100 37.6 24.3 19.7 8.7 – Gedaref PR 0.2 0.1 n/a 0.1 0.2 0.2 4.7 0.8 2.1 1.05 6 IN 87.6 46.1 0 62.1 100 75.4 2,379 359.0 861.0 – PR 0.005 0.01 0.01 0.1 0.1 0.01 0.03 0.3 0.2 0.08 14 IN 3.63 7.3 13.6 18.8 100 8.6 27.7 209.1 195.5 – S. PR n/a 0.003 n/a n/a 0.1 0.2 0.3 0.3 0.5 0.23 11 IN 0 2.4 0 0 100 148.2 252.5 294.8 453.7 – N. Darfur PR n/a n/a 0.01 0.2 0.2 0.2 0.4 0.9 1.0 0.4 8 IN 0 0 11.2 98.5 100 112.6 239.4 662.1 791.8 – W. Darfur PR 0.04 0.02 0.05 0.07 0.09 0.2 0.05 0.08 0.04 0.07 15 IN 0 0 23.5 139.5 100 103.7 0 0 0 – S. Kordofan PR .005 0.01 0.02 0.01 0.03 n/a 0.02 0.05 0.6 0.09 13 IN 11.6 32.6 60.5 32.6 100 0 79.1 230.2 1,802 – N. Kordofan PR 0.02 0.03 n/a 0.1 0.05 0.1 0.09 0.2 0.4 0.1 12 IN 46.2 52.7 0 196.7 100 237.4 254.9 541.7 1,313 – W. Kordofan PR n/a n/a 0.01 0.09 0.06 0.06 n/a n/a n/a 0.05 16 IN 0 0 23.5 139.5 100 103.7 0 0 0 – Source: Calculated from annual health statistical yearbooks for 2000–2008, Ministry of Health, Sudan.

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Years (The numbers 2-8 corresponds with the years 2002-2008)

FIGURE 3 Three-year prevalence rate of typhoid in Sudan, 2000–2008

Sudan has a heterogeneous physical envi- ronment, with different climates and habi- tats extending from near the equator to the Sahara Desert. In this physical environment live different societies with different local cultures, although the majority are Muslim. Education levels vary widely, and in many cases the various communities are separated geographically. These characteristics, of course, substantially influence the space– time behaviour of typhoid in Sudan.

Typhoid Prevalence at the Regional Level

Regional agglomeration distinguished northern, central, eastern, and western regions within Sudan (see Figure 4). The northern region includes the Northern and River Nile states; the central region includes Khartoum, Sinnar, White Nile, Blue Nile, and Gizira states; the eastern region includes Red Sea, Kassala, and Gedaref states; and the western region includes the north, south, and states in addition to the northern, southern, and western Kordofan FIGURE 4 states. Figure 5 builds on Figure 2 (which Geographical regions of Sudan depicts typhoid prevalence patterns in

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FIGURE 5 Three-year prevalence of typhoid by region, Sudan, 2000–2008 Sudan’s states) to presents typhoid preva- states in that region (although more are lence by geographical region. included in the western region), or to data Based on data for typhoid prevalence by limitations (many states have no records state and regional agglomerations indicated between 2000 and 2003), all of which may in “Data and Methodology” above, typhoid have affected the results. In addition, educa- prevalence was calculated by region (see tional, societal, environmental, and Table 2). The northern region shows a fluc- geographical differences are also important, tuating pattern, while the central region as proposed in the ESENGEO model. shows an increasing pattern, except for a These regional differences were statistically decrease in 2008. The eastern region is fluc- tested by analysis of variance (ANOVA), tuating, while the western region is stable for which found statistically significant differ- three successive years (2000–2002) and then ences in typhoid prevalence at the 0.001 shows steadily increasing prevalence during level both between and within regions of the remainder of the data period (2003–8). Sudan. Further, the calculated F-ratio is Small differences exist between the eastern greater than all other critical values at all and western regions in terms of average other significance levels, indicating that prevalence values, while both are remark- typhoid is a very serious problem across the ably different from the northern and central country. The fact that the central region regions, which showed similar values to ranks first in typhoid prevalence has envi- each other. Ranking of regional typhoid ronmental and socio-economic implica- prevalence puts the central region first, tions. This region is characterized by followed by the northern, eastern, and west- remarkable rainfall amounts and clayey soil, ern regions. and is home to the majority of Sudan’s popu- Three-year prevalence rates of typhoid lation. The spread of education has made were calculated by region (see Figure 5). more people aware of diseases and encour- Regional differences between the central aged them to visit doctors and attend hospi- region and other regions of Sudan may relate tals, and this is reflected in the official to population size, the inclusion of many records of typhoid infection. The presence in

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FIGURE 6 Spatial decay of three-year typhoid prevalence rates within ranked points representing states of Sudan (2000–2008) this region of large urban centres such as including the central and northern states. Greater Khartoum, Medani, and Kosti Environmental, socio-economic, and politi- creates its own environmental health prob- cal factors are primarily responsible for lems. At the same time, migration from rural these population movements. Table 3 shows areas in peripheral regions may tend to prevalence rates and state rankings in addi- increase the prevalence of typhoid in this tion to index numbers of typhoid prevalence region, since migrants tend to be illiterate, by state. poor, and lacking in personal hygiene. The Ranking states by the general preva- western region occupies the bottom rank, lence rate of typhoid (see Table 3) distin- which may relate, in addition to the absence guishes some states with rates far exceeding of statistical records, to the spread of illiter- those of Sudan as a whole (see Table 1), acy, political instability, and environmental including Khartoum and Blue Nile states. problems in a mostly arid and semi-arid Some other states have rates far below the environment, all of which may lead to under- general prevalence rate of typhoid in Sudan reporting of typhoid by making people less (e.g., Kordofan, Darfur, Red Sea, Kassala, likely to seek medical care when they are ill. and White Nile states). However, Northern, River Nile, Gizira, and Sinnar states show Typhoid Prevalence at the State Level very close rates to the national rate. Calculating the prevalence of typhoid by Calculations of the distribution of Sudan’s state also reveals two separate groups in population by states reveal an uneven distri- terms of typhoid behaviour over time. The bution. Ranking states by percent change in first group shows a fluctuating pattern of population for the period 2000–2008 distin- behaviour; the second group shows a steady guishes, first, the arid axis of rapid popula- increase in the prevalence rate. The first tion change, including the Red Sea area and group includes Red Sea, Gedaref, White western Sudan; and, second, the wet axis of Nile, Blue Nile, West Darfur, north slower population change around the Niles, Kordofan, , Kassala, and

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Sinnar states; the second group includes can be said that Sudan’s western states show Gizira, Khartoum, Northern, , both types of distribution patterns , , and River (continuously increasing and fluctuating). Nile states. Calculation of three-year typhoid prevalence Proportional change in typhoid by state rates by state reveals differences that are is shown by index numbers (see Table 3). For accordingly ranked and plotted (see Figure example, in Red Sea state, the index number 6). Figure 6 considers Sudan’s states as 99.3 for the year 2000 indicates that typhoid geographic points linked together by arrows prevalence is 0.97 % lower than for the base that decay with increasing ranking. The Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 year, 2004. Generally speaking, before 2004 arrow starts at Khartoum state (no. 1) and all states show a lower percentage than in the wanders around Sudan to settle finally in post-2004 period (2005–8), with a few west Kordofan state (no. 16). exceptions in some of the years under study. Ranking correlation by states between Discussion and Recommendations percent change in population and percent change in typhoid prevalence gives 0.01, a The general findings of this study are as very weak positive correlation. follows: Calculation of three-year prevalence 1 The prevalence of typhoid fever in rates by state distinguishes two major groups Sudan increased steadily from 2000 of spatial distribution of typhoid. The first through 2008. group, which shows a continuous increase in 2 Regional differences are remarkable typhoid, is centred around central and west- between the central region and other ern Sudan; it includes 9 states out of 16 regions of Sudan. (Khartoum, Gizira, Sinnar, White Nile, Blue 3 Geographic proximity influenced the Nile, South Darfur, North Darfur, North distribution of typhoid within Sudan’s Kordofan, and Northern states). This axis, states; contiguous states show a typical centred on Khartoum state, goes westward to pattern of typhoid behaviour, either include , north Darfur, and continuously increasing or fluctuating. south Darfur states and also south-eastward 4 Ranking correlation by states between to include Gizira, Sinnar, Blue Nile, and percent change in population and White Nile states. Its northward extension percent change in typhoid prevalence includes Northern state but is cut by River gives a value of 0.01, indicating a very Nile state, which belongs to the other group. weak positive correlation. The second group includes seven states These findings illustrate geographic making up two distinct pockets that show a and temporal variations in typhoid preva- fluctuating pattern of typhoid prevalence. lence by state. The reasons for such First is the eastern pocket, including Red variations are socio-economically, environ- Sea, Kassala, and Gedaref states, which mentally, and geographically related. The shortly goes westward to include River Nile states where prevalence of typhoid is high state; second is the western pocket, which during the data period are those of central includes west and south Kordofan and , and particularly Khartoum, Gizira, Darfur states. It is clear that geographic and Blue Nile states. These states are charac- proximity has influenced the distribution of terized by major economic investment, and typhoid within Sudan’s states. There is one consequently high population concentration huge geographical area of typhoid distribu- and increasing population, as well as rela- tion, including the central and western tively good per-capita income. In Khartoum states, in addition to relatively smaller pock- state, where Sudan’s capital city is located, ets including eastern and western states. It the population growth rate was 4.92 % in

The Arab World Geographer/Le Géographe du monde arabe 12, no 3-4 (2009) 184 Samir M. A. Hassan Alredaisy

1956, increasing to 7.76 % in 1973 and to other states with low recorded prevalence of 8.75 % in 1983, reaching 13.7 % in 1993 typhoid have, in addition to data limitations, (MFEP 1955–93). Mean population density small populations, particularly the western (number of persons per square kilometre) and Red Sea states. Although some parts of was 55.6 in 1973, 85.5 in 1983, and 169 in western Sudan receive more rain than 1993. Khartoum state received 39 % of inter- central Sudan, sandy soil conditions are nal migration in 1983 and 45 % in 1993 effective in ensuring water penetration and (MFEP 1955–93). Greater Khartoum’s thus do not provide such excellent niches for degree of urban primacy has changed: insect breeding. Similarly, River Nile and Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 whereas in 1955 Khartoum had 4.7 times the Northern states are characterized by desert population of Sudan’s second-largest urban conditions and low population density, with centre, by 1993 this had increased to 8.9 the population mostly concentrated along times (Davies 2001). The central states are the Nile. In these states, also, per-capita also where the large irrigated agricultural income is expected to be low relative to the schemes are found, such as the Gizira and central states. Rahad schemes, as well as the sugar facto- This discussion of typhoid prevalence ries of Kenana and Asalia. Institutions of rates in Sudan’s states is commensurate with higher education such as the universities of the statistics of the National Ministry of Khartoum and Gizira are found here, in Health for Sudan as a whole, which relate addition to the central government. typhoid to physical conditions, population Migration and natural population growth are factors, illiteracy, inadequate water supply, responsible for higher prevalence of typhoid and low governmental expenditure in the in these states. Studies in Sudan have docu- health sector. As of 2007, the adult literacy mented the tight relationship between popu- rate (for the population aged 15+ years) was lation mobility, migration, and congestion 49.9 % (50.9 % for men and 49.9 % for and the prevalence of diseases such as that of women). In 2006, 59.2 % of the population cholera and malaria (Alredaisy and Davies had access to safe drinking water; the 2003). However, the basic health infrastruc- expected benefit of improved water supply is ture provided does not match the increasing an 80 % reduction in typhoid rates (Fost populations of these states, although they 1976). In 2002, adequate facilities for the score high in their share of hospitals, disposal of excreta were available for only doctors, and primary health units (Ministry 31.4 % of Sudan’s population, and as of of Health 2008). 1999, was available for only The whole of Sudan central’s region is 70 %. These figures must be seen in context: characterized by climatic conditions the annual population growth rate was conducive to the spread of typhoid. In 2.53 % between 2003 and 2007, the natural Khartoum state, for example, average rate of increase was 41.23 per 1 000 in 2006, annual rainfall of nearly 161 mm is confined and the total fertility rate was 5.9 births per to the three months of July, August, and woman in 1999. This population growth was September, and during these months the not accompanied by proportional develop- daily temperature ranges from a mean mini- ment in the health sector. In 2000, the health mum of 25°C to a mean maximum of 38°C, sector received 2.08 % of the total budget; in while relative humidity averages 55 %. 2004, 1.68 %; and in 2005, 2.20 %, while These climatic conditions, which provide actual expenditure on the health sector in excellent grounds for insect breeding and 2007 was only 0.31 % of the total budget. transmission of typhoid, are further exacer- Between 2000 and 2008, the number of bated by clayey soil conditions and lack of hospitals increased from 309 to 395, an aver- proper systems for disposal of excreta. The age of only 9 new hospitals per year. Over

The Arab World Geographer/Le Géographe du monde arabe 12, no 3-4 (2009) Typhoid Fever in Sudan 185 the same period, the number of primary density, and concentration in order to detect health care units (PHCUs) was reduced from hazardous areas. Access to a map showing 2 558 to 2 005, while the number of health foreign and internal capital investment in centres (larger facilities offering more various regions of Sudan can help to forecast complex care) increased from 915 to 1 398. future population-movement trends and their The Ministry of Health (2008) also indicates consequences for public health. Geographical that the national avereage is 15.4 doctors per and environmental information for the 100 000 population, while Khartoum state ESENGEO model can also benefit from the has 65.5 doctors per 100 000 population. available typhoid fever incidence data, which Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 There are four states that have fewer than 20 have grown worldwide with efforts to doctors per 1 000 000 population, and six improve disease surveillance and the initia- states with fewer than 10 doctors per tion of population-based typhoid fever inci- 100 000 population . dence studies, in addition to advances in the This discussion show that lack of basic understanding of the age distribution of infrastructure and human and physical typhoid fever, allowing for measurement of conditions are dramatically influencing incidence rates among narrow age cohorts to typhoid prevalence rates in Sudan. There are be more accurately extrapolated to the gaps in the prevention of typhoid in Sudan general population. The formalization of that could be bridged by appropriate inter- methods for the assessment of typhoid burden vention. Such an intervention could be provides a framework for standardized meth- directed toward the whole of Sudan or ods (Crump, Luby, and Mintz 2004). Typhoid toward those states that have high prevalence does not appear as a major disorder in rates. It is generally assumed that there is a Sudan’s burden-of-disease estimates; need to educate people about typhoid; in although national programs addressing child reality, however, people are probably very health and survival recognize typhoid fever much aware of the disease but, because of prevention, reliable epidemiological informa- poor water and sanitary infrastructure and tion is needed on the burden and severity of because of perhaps population density, it is the disease in populations at risk in order to very difficult to prevent. This study could achieve consensus on case definitions, diag- build a very strong case for prioritizing nostic critera, and the appropriate mix of improved infrastructure in addition to preventive strategies (including carrier detec- educating people. This could be done by tion and water and sanitation interventions). incorporating the ESENGEO model (see Including disease management as a tool to Figure 1) in order to assess and reduce increase quality of care, improve patient typhoid infection and transmission in Sudan. outcomes, and control costs to reduce Building a case for prioritizing improved provider practice variation is a key aspect the infrastructure could depend on environmental ESENGEO model. Strategies for administra- and geographical information. tion of vaccines for preventing typhoid should Environmental information about typhoid in be deployed on a wide scale in ESENGEO, as Sudan should include relevant data on the recommended by WHO (2001), bearing in timing of the rainy season and all related mind that vaccine can control typhoid fever climatic characteristics at the state and only to a limited extent (Borgman 1994) and regional scales, to facilitate appropriate plan- that the eradication of a carrier state can be ning for control of insect breeding and the difficult (Kumar and Clark 1999). expected incidence of typhoid. Soil informa- People in Sudan can be educated about tion should also be introduced. Geographical typhoid symptoms, treatment, and preven- information should relate to population tion through school subjects such as geogra- growth, increase, mobility, migration, phy and biology and also through mosques,

The Arab World Geographer/Le Géographe du monde arabe 12, no 3-4 (2009) 186 Samir M. A. Hassan Alredaisy churches, adult education, media education, The application of the ESENGEO mobile cinema, and distance education. In model in Sudan can work to assess infection every state there are local broadcasting and and transmission of typhoid in order to television stations, a university, and decide on appropriate methods through acti- distance-education centres. All these facili- vation of the inputs, processes, and outputs ties can be used to educate people about outlined by the ESENGEO model, with the typhoid. Educational technologies encom- ultimate result of reducing typhoid in Sudan. pass electronic-based delivery methods and However, the ESENGEO model can also be innovations in instructional design such as applied for any other similar infectious Downloaded from http://meridian.allenpress.com/awg/article-pdf/12/3-4/173/1448496/arwg_12_3-4_477nm37355107610.pdf by guest on 29 September 2021 adult education, problem-based learning, disease in similar places in Africa, Asia, and and competency-based training. Distance Latin America. learning includes synchronous methods, which link learners who are separated by References geographic distance but allow for simulta- Alredaisy, S. M. A., and Davies, H. R. J. 2003. neous interaction, and asynchronous meth- The ecology of malaria in the squatter ods, which allow for interaction at different settlements of urban Sudan: Hai Gamier times (Muramoto, Campbell, and Salazar in Omdurman. Arab World Geographer 2003). Health education to prevent typhoid 6:178–93. Bensenson, A. S. 1975. Control of communica- includes education about personal hygiene, ble disease in man, 12th ed. Washington, especially regarding handwashing after D.C.: American Public Health Association. toilet use and before food preparation; use Borgman, E. F. 1994. Everyman encyclopedia, of safe drinking water; excluding disease 5th ed. London: J. M. Dent & Sons. carriers from food handling; and antibiotic Crump, J. A., Luby, S. P., and Mintz, E. D. 2004. treatment. The global burden of typhoid fever. Bulletin Social capacity building on typhoid of the World Health Organization awareness in Sudan can positively be 82:346–53. enhanced through religious and cultural http://www.who.int/rpc/TFDisBurden.pdf norms encouraging personal hygiene and Crump, J. A., Youssef, F. G., Luby, S. P., Wasfy, neighbourhood sanitation where God’s M. O., Rangel, J. M., Taalat, M., Oun, S. A., and Mahoney, F. J. 2003. Estimating the rewards are endless, ethnoscience concerned incidence of typhoid fever and other febrile with symptoms and treatment of typhoid, illnesses in developing countries. Emerging conscious use of herbal medicine, and the Infectious Diseases 9:539–44. help of traditional healers and curers capable Davies, H. R. J. 2001. Population change in the of transmitting correct information on Sudan during the twentieth century. Sudan typhoid to indigenous people. Youth clubs Studies 27:31–55. and school vacations can be opportunities Fost, N. 1976. Review of Human rights in for volunteer work in typhoid campaigns and health: Ciba Foundation Symposium 23, prevention. Charitable donations can be 1974. Pediatrics 58:634–35. used to provide sanitary materials for poor IRIN. 2010. Gabon: Typhoid outbreak extends to people and for public bathrooms; posters capital hit by water supply problems. Libreville: IRIN Humanitarian News and and other materials to raise awareness about Analysis, 25 January. http://www.irin- typhoid in public gathering places (markets, news.org/report.aspx?reportid=52796 central bus stations, mosques, churches, Kumar, P. J., and Clark, M., eds. 1999. Clinical etc.); and funding for local people’s commit- medicine: A textbook for medical students tees, administrative localities, and youth and doctors, 4th ed. London: Baillière clubs to work for environmental sanitation in Tindall. their neighbourhoods, including monitoring Lucas, A. O., and Gilles, H. M. 2003. Short text- suspected insect breeding locations. book of public health medicine for the trop-

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