University of medical sciences

and technology
Research Proposal
Socio-economic Impact of Kala-azar in
In Bazoura and Umkuraa hospitals, ElGedarif, during the period September
2010 to February 2011.

Supervised by:
Dr. Eman Basheer
Prepared by :
Abdullah Muhammed El-Fakki
Batch (13)
MD-2006-01
Background:
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Kala-azar is a serious health problem in over 88 countries worldwide

with an estimated 500,000 people infected, 12 million have active disease.
Millions in Africa are unable to live healthy and productive life because they
are incapacitated by various parasitic and infectious diseases; one of which is
leishmaniasis (WHO, 2006). Current data suggest that these parasitic and
infectious diseases could be the cause of about 25% of disability adjusted life
years (DALYs) where it causes

2 357 000 disability-adjusted life years

(DALYs) lost, placing leishmaniasis ninth in a global analysis of infectious

diseases (Alvar et al, 2006). Control of these neglected diseases is a crucial
step towards achieving the Millennium Development Goals ( Fenwick et al,
2005).

Leishmaniasis is a disease caused by the protozoa of the genus Leishmania,

transmitted by the bite of female sand fly. There are several methods to
classify leishmaniasis based on the geographical distribution into old wolrd
and new world Leishmaniasis, or based on the taxonomy of the parasites into
five mail are available, clinically, it can present itself in various forms, and is
more

easily

classified

as

cutaneous,

mucocutaneous,

and

visceral

leishmaniasis (Imam, 2009). Kala azar is the Indian name for visceral
leishmaniasis. The term means "black disease," which is a reference to the
characteristic darkening of the skin that is seen in patients with the disease
(Stark, 2010). Poor nutrition, infection, and other stresses predispose patients

to increased morbidity and mortality rates. Conditions such as complex

emergencies, mass migration, and famine accelerate the development of the
disease. Leishmaniasis is responsible for an estimated 80,000 deaths
annually (Guerin

et al, 2002).

Visceral leishmaniasis is a progressive disease,

with mortality rates in untreated cases ranging from 75-95% or as high as

100% within 2 years. In developing countries like many of the neglected
tropical diseases drugs used for treatment of leishmaniasis are toxic and
expensive (Sundar et al, 2000).
In Sudan kala-azar is known to be endemic in the areas extending from
El-Gedarif to the Upper Nile and Bahr el Ghazal provinces. Visceral
leishmaniasis has been shown to have gender bias affecting more males than
females. A fatal type of visceral leishmaniasis, which is reported along the
Mediterranean cost, specifically affects infants. Although the prevalence is
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proportional to sand fly exposure, children younger than 15 years represent a

large proportion of cases in endemic areas ( Zijlstra et al, 1994).
Leishmaniasis has a grave social impact due to the morbidity of the disease,
which can cause severe deformities and disfigurement and lead to social
isolation. Socio-cultural system are considered as an important aspect
concerning communitys understandings and development since it plays an
important and a vital role in determining availability and usage of resources to
serve the development ( Ismail 1997). The main problem that faces
developing communities is that they have traditions that built tough social
barriers making individuals lacking many of the important qualification to
achieve development. Much community sees the disease from his own
cultural point of view and that's why understandings of diseases are
considered as a marker for community's development. Diseases are not only
changes on the health status of the patient but they also include changes on
his roles towards the community and deprivation of him from work so affecting
the patient's income.
The World Health Organization and the U.S. Centres for Disease
Control and Prevention have recently identified a set of diseases as targets of
opportunity in the effort to improve global health, while creating more vigorous
economies and a better quality of life some of the worlds poorest countries
(NTDC, 2006). Neglected Tropical Disease Coalition was established by the
two organizations to work on these diseases providing drugs for them from
donations to the political authority in the area to distribute them for free But in
spite of these facilities patients have to pay for different visits to different
governmental providers and even they may pay informal payments for
provider access, diagnostics and drug administration and some patients do
not have access to drugs and thats why they can't afford to pay for the
complete course which has high cost sometimes higher than the patients
income and this causes major economic burden in affected families ( WHO,
2006) Economic factors play a significant role in development, so any

reduction in the income level may form an important barrier in front of

development. There are scarce health care services and low individual income
in third world countries which constituted 3.7 percent of the gross domestic

product in 2002 as compared to 18.5 percent of the gross domestic product in

2002 in developed countries (IMF, 2005). .
Kala-azar is serious health problem in Gedaref state, eastern Sudan
where its incidence has reached as high as 38 cases per 1000 person years.
In this region, VL is caused by 3 zymodemes of Leishmania donovani,
classified as L. d. donovani, L. d. infantum and L. d. archibaldi. The only
vector there is Phlebotomus (Larroussius) orientalis, which thrives in habitats
characterized by Acacia seyal and Balanites aegyptica trees and black cotton
soils.
Transmission of the disease takes place both in A. seyal and B.
aegyptica woodland and inside villages. It is probable that both anthroponotic
and zoonotic transmission of L. donovani take place in eastern Sudan
(Elnaiem et al, 2003).

Justification:
Neglected tropical diseases (NTDs) exist and persist for social and
economic reasons that enable the vectors and pathogens to take advantage
of changes in the behavioral and physical environment. Persistent poverty at
household, community, and national levels, and inequalities within and
between sectors, contribute to the perpetuation and re-emergence of NTDs.
Changes in production and habitat affect the physical environment, so that
agricultural development, mining and forestry, rapid industrialization, and
urbanization all result in changes in human uses of the environment,
exposure to vectors, and vulnerability to infection. Concurrently, political
instability and lack of resources limit the capacity of governments to manage
environments, control disease transmission, and ensure an effective health
system. Social, cultural, economic, and political factors interact and influence
government capacity and individual willingness to reduce the risks of
infection

and

transmission,

and

to

recognize

and

treat

disease.

Understanding the dynamic interaction of diverse factors in varying contexts

is a complex task, yet critical for successful health promotion, disease
prevention, and disease control. In the light of this the socio-economic

impact of kalazar has not been studied in any great depth in Sudan; and on
the other hand there are new emerging foci for the disease and there is
expansion of the existing foci. And these factors show the importance of this
study.

Objectives:
General objectives:

To determine the socio-economic impact of kala-azar in affected

communities in eastern Sudan

Specific objectives:

To assess public knowledge and awareness about the disease.

To assess effect of the disease on the social life.

To assess psychological trauma associated with the disease.

To assess the burden of the disease on the family's income.

Materials and Methods:

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Hypothesis:

Kala-azar affects the socio-economic status of affected families and

communities.

Methodology:
Study design:

Cross-sectional descriptive community based study.

Study area:
The field survey was done in Gedaref state, eastern Sudan. According
to the most recent estimates, Gedaref state has a total population of 1137 642
inhabitants. Gedaref State extends over 71,621 km2 bordered in the east by
the Ethiopian Frontier, in the south and the west River Rahad, and in the
northeast by the Atbara River. The region is a flat plain, with almost no relief
other than small, scattered hills and seasonally flowing watercourses, most of
the land is covered by black cotton soils, with few scattered sandy places,
known locally as azaza soils. The climate of the area is tropical continental
with an estimated annual rainfall between 400 and 1400 mm. The year is
sharply divided between a rainy season (JuneOctober) and a dry season
(NovemberMay). Dry savannah wood-land is the natural vegetation of
Gedaref state. B. aegyptica (known locally as hig-leeg), A. seyal (taleh), A.
senegal (hashab), A. mellifera (kiter) and Combretum spp. are the most
abundant indigenous trees.
The study was conducted in Bazoura and Umkraa (Um-Elkhair)
hospitals, Bazoura hospital is situated south to Hawwata built by institute of
endemic diseases but now taken over by the Gedaref state ministry of health;
Umkraa (Um-Elkhair) hospital, situated close to River Rahad, Established by
Mdecins Sans Frontires-Holland (MSFHolland) and now also taken over by
Gedaref ministry of health, now both hospitals has became a research centre
for endemic diseases as well as hospitals receiving the different patients
especially Kala-azar. The analysis depended mainly on patients with VL
admitted to these 2 treatment centers, the data was collected from the 2
treatment centers and assumed representative of all areas within the region
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since visceral leishmaniasis is a serious health hazard, which people

recognize to have a fatal outcome if not treated, and most victims needed
inpatient treatment.

Sample size and sampling technique:

The folllwing equation will be used to determine the sample size
N = [(Z*P*Q)/D]*d
N= sampling size
Z= 1.96
P= population proportion estimated from previous study (Prevalence)
Q= 100-p
Z= confidence level set conventionally at 95% (1.96)
D= desired marginal error. (0.05)
d= design effect =3
Then sample size:

N= [(1.96)*(0.032)*(1-0.032)/ (0.05) ]*3 = 48*3 =114

Sampling technique: simple random sampling will be

used for recruitment of participants.

Data collection technique and tools:

Socio economic studies uses a lot of techniques for data collection and
that because of the social life nature and this research will depend on:
-

Observation: which is considered as one of the toolsthat helps in

data collection from the real life incidents and just from observation
we find that this disease affect and got affected by the socioeconomic aspects of life.

Questionnaires will be used to assess the socio-economic effects of

kala-azar on the community and this will be administered to the
local authorities.

One of the parents/ guardians will be consented and interviewed for

completion of the specially designed questionnaire for this study
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The data
The data on which the study is based were primary data collected from the
sampling units using a questionnaire.

Methodology and statistical:

The data obtained will be processed and analyzed using Statistical
Package for Social Sciences version 17 (last version).

Ethical consideration:

The approval of the local community authority will be sought in the visit
after full explanation of the study purpose.

Verbal informed consent from the hospital administration.

Health education will be given to the patients

The study will be approved by the University ethical committee.

Budget:
Action
Questionnaire distribution
Travel expenses
Bus ticket to El-gedarif (return)
Hotel stay in el-gedarif
Stationary
Grand total

SDG
300
500
150
500
50
1500

Work plan:
Time September October November December January
Writing the proposal
Revising previous
researches
Preparing
questionnaires
Start of project
Distribution of
questionnaire
Analyzing data
Writing final report

February

Annexes:
1. Questionnaire used in the study:

2010 / /

:
/

:
(1:

(2:

20

40 -20
40
(3 :

(4 :

(5 :

(6:

200
200-500
500-1000
1000
9

 :
(7 / :

)8

)9

10) 100-70
40-69%
<40%

:
/ :

)11

................................................... )12
.............................................. / )13
.................................................... )14
(15 :

(16
..................................................................................................................
(17 ...........................................
(18 :

(19 / .................................................
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 (20 ......................................................................
(21 ...........................................
(22 :

(23
.......................................................................................................
(24 ........................................................................................
(25 ...........................................................................................
(26 ..........................................................................................
(27 ..........................................................................................
(28 .............................................................................................
(29 ............................................................................
(30 +......................................................................
:
:

)14

)15

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2. Map showing world distribution of kalaazar:

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References:
1- World health organization, executive board 18 th edition 11 may 2006.
2- Jorge Alvar, Sergio Yactayo, and Caryn Bern, Communicable Diseases,
Neglected Tropical Diseases Control, World Health Organization,Division of
Parasitic

Diseases,

Centers

for

Disease

Control

and

Prevention,

leishmaniasis and poverty, trends in parasitology, December, 2006. (22) ,552557.

3- Fenwick A, Molyneux D, Nantulya V (2005) Achieving the Millennium
Development Goals. Lancet 365: 10291030.
4-

Imam, T.S, THE COMPLEXITIES IN THE CLASSIFICATION OF

PROTOZOA: A CHALLENGE TO PARASITOLOGISTS, T Bayero Journal of

Pure and Applied Sciences, 2(2): 159 - 164
5- Craig G Stark, MD, Regional Medical Director, leishmaniasis, web MD
health pdrofessional network, 2010.
6- Philippe J Guerin, Dr Piero Olliaro, Professor Shyam Sundar, Marleen
Boelaert, Simon L Croft, Philippe Desjeux, Monique K Wasunna, Anthony DM
Bryceson, Visceral leishmaniasis: current status of control, diagnosis, and
treatment, and a proposed research and development agenda, The Lancet
Infectious Diseases, Volume 2, Issue 8, Pages 494 - 501, August 2002.
7- Sundar S, More DK, Singh MK, et al. (October 2000). "Failure of
pentavalent antimony in visceral leishmaniasis in India: report from the center
of the Indian epidemic". Clin. Infect. Dis. 31 (4): 11047.
8- Zijlstra, E. E., El-Hassan, A. M., Ismael, A., Ghalib, H. W., (1994), Endemic
kala-azar in eastern Sudan: a longitudinal study on the incidence of clinical
and subclinical infection and post kala azar dermal leishmaniasis. Am. J. Trop.
Med. Hyg. 51(6): 826-36.
9- Amine Zakareeya Ismail, University of Khartoum, socioeconomic impact of
malaria in Almansheeya and Aldikhainat, institute of endemic diseases, 1997.
10- The Neglected Tropical Diseases Coalition, Who we are, 2006.

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11- IMF, World Economic Outlook, Washington D.C., September 2005 and
April 2006. Pp. 2, 16, 43, 52, 189, 191,194 and 205.
12- D-E.A. Elnaiem,A.M. Mukhawi,M.M. Hassan,M.E. Osman,O.F. Osman,
M.S. Abdeen and M.A. Abdel Raheem. WHO Eastern Mediterranean Region
(EMRO), Factors affecting variations in exposure to infections by Leishmania
donovani in eastern Sudan, eastern Mediterranean health journal, 2003
Jul;9(4):827-36.

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