Typhoid Fever in Sudan: Some Geographic and Time Considerations from 2000 through 2008 Samir M. A. Hassan Alredaisy Department of Geography, Faculty of Education, University of Khartoum, 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 Gezira, 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, The Arab World Geographer/Le Géographe du monde arabe 12, no 3-4 (2009) Typhoid Fever in Sudan 175 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 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.