Schistosomiasis and its social determinants: an ancient neglected tropical disease case in Sudan

Colley et al. Lancet

Keywords: Schistosomiasis, Social Determinants; Sudan; water-born-diseases; NTDs

 

Sudan is a country once considered as the breadbasket of Africa, its irrigation schemes made the country rich in cotton and other agricultural products; however, decades of mismanagement, harsh climate and political difficulties meant that this is now vestigial. (1)

Sudan has a population, of 41 million, and is highly diverse, consisting of about 19 different ethnic groups and almost 600 subgroups with More than 80% of the Sudanese population lives in rural areas or nomadic.  which presented a significant challenge for diseases control initiatives. (2) furthermore, the sustained conflicts have limited Sudan’s opportunities for socio-economic development, and has increased poverty across the country, according to the National Baseline Household Survey 2010, 46.5% of the population is impoverished, with 57.6% living below the poverty line in the rural areas. (3)

Schistosomiasis is a water-borne trematode infection that occurs in 78 countries and is most prevalent in sub-Saharan Africa, where more than 90% of those infected live.

 Sudan being in the Eastern Mediterranean WHO region with prevalence reached over 25% and much higher in western states (Darfur) where the urogenital type is endemic. (4)

 Schistosomiasis is widely recognized as a socially determined disease, understanding the social and behavioral factors linked to the disease transmission will enable better prevention and control measures. (5)   This essay aims to shed light and to identify these social determinants of the Schistosomiasis disease in Sudan and the current interventions.

Social Determinants of schistosomiasis

Schistosomiasis transmitted via contaminated freshwater, and in Sudan, 26% of the people reported practicing open defecation, with further the majority of the population relying on fetching water from surface-water sources or shallow groundwater-wells, which present a high risk of contamination (1). Furthermore, with this precarious water and sanitation conditions further are exacerbated by the country’s exposure to extreme climate events and population mobility with an increase in poverty rates, wars, and political instability. (6) all these factors contribute to the current disease prevalence disparities.

 Looking into the distribution of the schistosomiasis prevalence in the country the burden of the disease is in the young age, women and quite preponderant in the areas where there are conflicts and high rate of poverty, low level of education, and literacy. Adding to very scarce existence of health care services in the fragile and conflict-affected areas like Darfur region, with some highly endemic urban areas like in Farmer’s area in new Halfa,  White Nile and Gizera provinces. (7, 8,9)

 

To summarize and characterize these determinant identified in Sudan and the relationships that link these social determinants:

First the structural social determinants found are age, gender, socio-economic status of the family, low educational level, lack of health awareness, employment as farmers and living in rural areas with no latrine are major social determinants, at the individual level; Age and gender are particularly being powerful determinants as most affected groups are young age adolescents and girls because they are the most active in fetching water in families in Sudan, and the awareness is very low among them as well; which increase the chances of exposure to schistosomiasis-contaminated water. Whereas, at the State level, the overall political instability and non-participation in the governance which generate negligence and marginalization, economic status and poverty, percentage of literacy, lack of infrastructure and safe water, community engagement and policies are the most commonly associated factors for schistosomiasis.

 The Social determinants interplay.

Schistosomiasis and poor health consequences

Existing Interventions to fight Schistosomiasis in Sudan

Although the federal and state directorates for schistosomiasis control and prevention  initiated a community-wide mass treatment, started at district level with coverage aims at 75% of school children, which is considered the only good political commitment by the government to avail accessible drugs but this ineffective and will not benefit 2.2 million people at the highest endemicity zones, whilst 1.7 million people would receive the Mass treatment intervention unnecessarily. (9)

 

Conclusion and Recommendations:

 

Schistosomiasis is a disease that is widely socially determined and its transmission is the result not only of the interplay between humans, snails, and parasites, but also of complex political, socioeconomic, and cultural processes, so Preventive strategies that are soundly based on an understanding of the social context of schistosomiasis and not focus solely on treatment, then can have a greater impact on the disease elimination.

At the states level, policies should focus should be on Reducing health inequity through a social intervention that needs to exert many efforts, commitment, infrastructure, political will at national and state level, and involving all sections of the society.

 Prioritizations for research on the social determinants of schistosomiasis and awareness.

Multi-sectorial health policies in education, agriculture, and water, plus the local villages’ stakeholders need to be educated towards the importance of the social determinants and their role toward health system strengthening which is necessary to address rural population needs.

 

Fathelrahman Ibrahim: A Clinical Researcher, holds a double Master's degree in Clinical research-International Health at the University of Barcelona, Spain, MSc in Molecular Medicine at the Institute of Endemic Diseases UoK,  has years of work experience in humanitarian relief and development; focusing on Diagnostics and laboratory Medicine; Experienced in Tropical diseases epidemics, Emergency preparedness, and response. 

Email: ifathelrahman@gmail.com

 

 

References:

1.     Charani E, Cunnington AJ, Yousif AHA et al. In transition: current health challenges and priorities in Sudan. BMJ Global Health 2019;4:e001723. doi:10.1136/bmjgh-2019-001723 https://gh.bmj.com/content/bmjgh/4/4/e001723.full.pdf

2.      Elamin A, Ibrahim ME, Abuidris D, Mohamed KE, Mohammed SI. Part I: cancer in Sudan—burden, distribution, and trends breast, gynecological, and prostate cancers. Cancer Med. 2015;4(3):447–456. doi:10.1002/cam4.378

3.      https://www.unicef.org/mena/media/1816/file/MENA-CMReport-SudanBrief.pdf  accessed 11 November 2019

4.      Cha, S., Hong, S., Lee, Y. et al. Nationwide cross-sectional survey of schistosomiasis and soil-transmitted helminthiasis in Sudan: study protocol. BMC Public Health 17, 703 (2017) doi:10.1186/s12889-017-4719-4

5.    https://www.gov.uk/dfid-research-outputs/the-social-context-of-schistosomiasis-and-its-control-an-introduction-and-annotated-bibliography

6.      https://www.hrw.org/world-report/2019/country-chapters/sudan

7.  Afifi A, Ahmed AA, Sulieman Y, Pengsakul T. Epidemiology of Schistosomiasis among Villagers of the New Halfa Agricultural Scheme, Sudan. Iran J Parasitol. 2016;11(1):110–115.

8.  Sulieman Y, Eltayeb RE, Pengsakul T, Afifi A, Zakaria MA. Epidemiology of Urinary Schistosomiasis among School Children in the Alsaial Alsagair Village, River Nile State, Sudan. Iran J Parasitol. 2017;12(2):284–291.

9.    Cha, S., Elhag, M.S., Lee, Y. et al. Epidemiological findings and policy implications from the nationwide schistosomiasis and intestinal helminthiasis survey in Sudan. Parasites Vectors 12, 429 (2019) doi:10.1186/s13071-019-3689-z.

10.Colley et al. Human schistosomiasis. Lancet. 2014 June 28; 383(9936): 2253–2264. doi:10.1016/S0140-6736(13)61949-2