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First dengue outbreak in the Darfur region, West Sudan: an Infectious Thoughts interview

The Darfur region in western Sudan has suffered from both conflict and civil unrest which have caused high levels of internal displacement, immigration, and substantially fragilised infrastructure and communities. Severe cases of febrile illnesses were reported from different areas of Darfur which, given weak healthcare structures, were often clinically diagnosed as malarial infections. A recent study has investigated the likelihood of arbovirus infections and established the region's first dengue outbreak. In this Infectious Thoughts interview, we speak with Ayman Ahmed from the University of Khartoum's Institute of Endemic Diseases about the current epidemiology of viral diseases in Darfur; the ongoing gaps in research, laboratory capacity and funding; as well as the urgent international partnerships needed to monitor and improve public health for these neglected patients.

What was the rationale behind your study?

The Darfur area has suffered from an armed conflict and civil unrest that has led to massive internal displacement and immigration; this in turn made the community very fragile. In the absence of basic services including proper health care, severe cases of febrile illnesses were reported from different areas of Darfur. Most of these cases were treated as malaria cases because Sudan is a high-burden and high-risk country for malaria, therefore malaria is the primary suspected at any health issue, and with a lack of basic diagnostic tools, most health care providers rely on clinical diagnosis for the treatment.

Unfortunately, cases continued to die and when blood samples were tested microscopically, they were negative for malaria. We deployed our investigation team to the area, having in mind that the area has a recent history of yellow fever epidemics and the fact that most cases were manifested by bleeding. We suspected the diseases to be one of the haemorrhagic fevers, mainly one of the major arboviruses including: dengue fever (DF), yellow fever (YF), Rift Valley fever (RVF), Crimean-Congo Hemorrhagic Fever (CCHF), West Nile virus (WNV) chikungunya virus (CHIKV), and Zika virus (ZIKV), because all of them are endemic in Sudan.

What are some of the main diseases and conditions which the patients in your study are likely to be at risk of?

The Darfur area is at risk of several infectious diseases - the list of diseases reported from the area includes but is not limited to malaria, leishmaniasis, DF, YF, RVF, CCHF, WNV, CHIKV, and ZIKV. We believe that the armed conflict and increased population density (particularly those people living in high density refugee’s camps) and dynamics (high mobility within the country and between the neighbouring countries) in the area have deteriorated the public health issues in the area. Many other infectious diseases might have been introduced into the area but remained un-noticeable due to the weakness of the health system.

What were some of the difficulties which you encountered in trying to isolate the DENV1 and 3 viruses in the populations studied?

The major difficulty we encountered in our study was the limited blood samples donated by the research participants, in some cases even the amount of donated samples was not enough to perform a single test on them. This mainly was due to the fact that people of this area have suffered from exposure to long-term armed conflict which has made them feel insecure even to seek health care services.

What policy implications would your current research have?

There are many health policy implications of our study - first and foremost the need for strengthening and expanding health care services, particularly in humanitarian and post-conflict settings. In addition, there is an urgent need for a country-wide surveillance system to detect the emergence of infectious diseases as early as possible to control them and prevent their establishment into new areas. Also, we need a new policy about sharing the data of health emergencies and epidemics rapidly to get the affected community all the supports they need as soon as possible.

What other research and further investigations would you envisage undertaking?

We were not able to isolate the circulating viruses to sequence them and study their phylogeny to investigate their sources and potential risk factors. Also as we have detected the active co-circulation of Crimean-Congo Hemorrhagic Fever (CCHF), West Nile virus (WNV) in the area, further epidemiological studies are urgently needed to investigate the burden of arboviral diseases in the area as well as the risk factors associated with them for a better strategic planning and implementation of prevention and control measurements.

Are you looking for particular partnerships and collaborations?

Definitely yes! We are in extreme need for international partnership and collaboration to improve the public health of our local communities. We have a huge gap in our knowledge, skills and research capacity particularly about arboviruses, although we have established the first Arbovirology Unit in Sudan at the Institute of Endemic Diseases, University of Khartoum last year, but it still not fully functioning. Therefore, we are looking forward to improving our research capacity as this will be a driving force to improve our health system by generating evidences needed for decision making and raising the awareness of policymakers and health care providers, and building the capacity of our health care providers.

Is there a specific technology which you would like to see developed or deployed in order to facilitate your research and next steps?

Technological gap is a main hindrance for the development of our health system and research capacity, as for instance we do not have a simple sequencer in the entire country and it is not easy for us to get access for external sequence services due to the lack of funds. Advanced and sensitive diagnosis devices play a major role in the early detection and prevention of epidemics. Unfortunately, huge number of deaths could be averted if we could detect the causative agents of epidemic on time and tremendous resources will be saved. As you can see in all epidemics reports from Sudan, it is commonly takes several months before our Ministry of Health declare the epidemics because they need to send the samples for an external reference laboratory for validation before the official confirmation. Hopefully, with the establishment of our new unit of Arbovirology, local and international partnership and collaboration this will change soon and we will be able to save many lives most of them are children and women (most vulnerable groups in Sudan).

How do you fund your research?

The only available fund for researchers in Sudan is the WHO/TDR Small Grant Scheme which does not exceed 15,000 USD and it is extremely difficult to get funds from somewhere else. It is understandable that international funds are politically influenced but in case of epidemics, health emergencies, and their prediction, investigations and responses, the case should be different because this will put many lives at risk specially that these diseases does not know any borders and could be exported and imported into several countries instantly.

What is your final message to our readers?

I would like to take this opportunity to thank the International Society for Neglected Tropical Diseases (ISNTD) for their concern about our recently published work and the health issues of the tropical countries.

Also, I would like to urge all our peers and colleagues in biomedical and public health research institutes, funders and donors, NGOs, and other related institute worldwide to acknowledge our gap in research capacity and understanding that this gap exist in a country endemic with at least seven major arboviral diseases (DF, YF, RVF, CCHF, WNV, CHIKV, and ZIKV) in addition to several other vector-borne diseases such as malaria, leishmaniasis, and onchocerciasis. In conclusion, we strongly believe in partnership and collaboration to improve health research and people lives, and we are welcoming all of them and looking forward to have a very productive long-term collaboration with our global peers.

Link to full article:

The First Outbreak of Dengue Fever in Greater Darfur, Western Sudan Ayman Ahmed 1,2,* OrcID, Adel Elduma 3, Babiker Magboul 4, Tarig Higazi 5 and Yousif Ali 4 1 Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan 2 Department of Vector Biology, Liverpool School of Tropical Medicine (LSTM), Liverpool L3 5QA, UK 3 Epidemiology Department, National Public Health Laboratory, Khartoum 11111, Sudan 4 Health Emergencies and Epidemics Control Directorate, Sudan Federal Ministry of Health, Khartoum 11111, Sudan 5 Department of Biological Sciences, Ohio University, Zanesville, OH 45701, USA

Biographical Sketch of Ayman Ahmed:

Mr. Ayman Ahmed, M.Sc. Mr. Ayman Ahmed is a Research Fellow at Institute of Endemic Diseases, University of Khartoum, Sudan, and a Wellcome Trust Master's Fellow of Public Health and Tropical Medicine at Liverpool School of Tropical Medicine (LSTM), UK. He is interested in building an outstanding research career in Arbovirology and developing a strategic public health policy for the prevention and control of arboviral diseases and haemorrhagic fevers in Sudan.

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