Fifty years of Sudanese hospital-based obstetric outcomes and an international partnership.

OBJECTIVE: To present 50 years of hospital-based maternal and perinatal outcomes in Sudan, and the role of an international collaboration with an Irish maternity hospital, over the period 2002-2009, in recent health-indicator improvements. DESIGN: Retrospective descriptive study. SETTING: Omdurman Maternity Hospital, Sudan. POPULATION: All women who delivered at Omdurman Maternity Hospital, and their newborn infants, from July 1957 to October 2007, comprising 339 448 births. METHODS: The original logbook data was extracted. Infant and maternal health indicators were calculated according to World Health Organization definitions. MAIN OUTCOMES MEASURES: Total annual births, maternal mortality ratio and maternal complications, neonatal mortality and stillbirth rates, and rates of delivery methods. RESULTS: Total births increased 50-fold from 499 in 1958 to 24 913 in 2007. Significant reductions in morbidity and mortality began in the mid-1990s. From 2001 to 2007, maternal mortality fell from 329 to 36 per 100 000 live births: an 85% reduction. Stillbirth rates almost halved, from 35 to 19 per 1000 births in 2001 and 2007, respectively. Neonatal mortality rates remained largely static, at 24 per 1000 live births in 2007, but there is recent evidence of a decline. CONCLUSION: This hospital-based data offers a unique historical portrait of health outcomes in one of the largest maternity hospitals in Africa, and shows steady, sustained improvements in maternal, stillbirth and neonatal mortality rates since the 1990s. The partnership was associated with a number of positive infrastructural, educational, and staffing achievements. Whether it directly contributed to improved health outcomes has not been established.

Prevalence of IDDM in schoolchildren in Khartoum, Sudan.

The prevalence of insulin-dependent diabetes mellitus (IDDM) in 42,981 schoolchildren (aged 7-14 yr) in Khartoum, Sudan, was determined. With the 1985 World Health Organization revised criteria for diagnosis and classification of diabetes mellitus, the overall crude prevalence rate of IDDM was 0.95/1000 in the age groups studied. This figure is thought to reflect the minimum prevalence of IDDM in that population, because there is an inherent tendency in the method of screening used toward underestimating the true prevalence rate. The prevalence of IDDM was found to increase significantly with age and was slightly higher in girls than boys, but this was not statistically significant. Of 41 children with IDDM detected in the survey, 7 were not known to have IDDM before but were showing suggestive symptoms at the time of the study. This study showed that IDDM in childhood is not rare in Sudan and that probably a substantial number of undiagnosed cases exist.

Epidemiology of childhood type I diabetes in Sudan, 1987-1990.

OBJECTIVE: To determine the incidence of type I diabetes in children 0-14 yr of age in Khartoum, Sudan. RESEARCH DESIGN AND METHODS: Prospective registration of newly diagnosed patients in a hospital-based registry with independent validation of completeness of case ascertainment. Eligible patients were Sudanese children < 15 yr of age, who developed type I diabetes during the period 1 January 1987 through 31 December 1990, and who were living in Khartoum city at the time of diagnosis. The denominator is the stable childhood population of Khartoum city, as estimated by the National Bureau of Statistics. RESULTS: In 4 yr, 239 cases were notified in the primary source and 268 in the secondary source. Some 196 patients were registered in both sources. Using the capture-recapture method to correct for underascertainment, the estimated total number of cases was 327, and the overall degree of ascertainment was 95%. The incidence of type I diabetes in children 0-14 yr of age increased from 5.9/10(5) in 1987 to 10.1/10(5) in 1990 (P < 0.001). Girls exhibited slightly higher incidence rates than boys in the 10-14-yr age-group throughout the 4 yr, but the differences were not statistically significant. The age distribution at onset was bimodal with a clear peak at age 12 yr in girls and age 14 yr in boys and another smaller peak at age 7 yr in both sexes. The number of new cases was markedly higher in the cooler months of the year, with a peak in January and a nadir in June (P < 0.01). This trend was consistent over the period of observation. CONCLUSIONS: Childhood diabetes is increasing in Sudan. Our incidence figures are higher than those reported from other Arab countries and is similar to reports from France and Italy.

Aflatoxins and kwashiorkor: clinical studies in Sudanese children.

Aflatoxin analysis of blood and urine by high performance liquid chromatography in 584 Sudanese children is reported. The results in 404 malnourished children comprising 141 kwashiorkor, 111 marasmic kwashiorkor and 152 with marasmus are compared with 180 age-matched controls and correlated with clinical findings. The aflatoxin detection rate and mean concentration were higher in serum of children with kwashiorkor than the other groups. The difference between the detection rate in kwashiorkor and controls was significant (p less than 0.05). The aflatoxin detection rate in urine was highest in the marasmic kwashiorkor group and the mean concentration was higher in the marasmic kwashiorkor and marasmic groups than in the kwashiorkor and control groups. There were important differences in the detection of certain aflatoxins between the groups. Aflatoxicol was detected in the sera of 16 (11.6%) kwashiorkor, in six (6.1%) marasmic kwashiorkor, but in none of the controls and only once in marasmus. These differences are highly significant (p less than 0.0001). The ratio of AFB1 to AFM1 was higher in the sera and urines of kwashiorkors than in controls, suggesting that the normal transformation of AFB1 to AFM1 may be impaired in kwashiorkor with consequent increase in transformation of AFB1 to aflatoxicol. The study therefore provides evidence of differences in the metabolism of aflatoxins in children with kwashiorkor compared with children with other forms of malnutrition and normally nourished children and confirms the association between aflatoxins and kwashiorkor contained in a preliminary report on this work.

Islet-cell antibodies and endogenous insulin secretion in Sudanese diabetic children.

Cytoplasmic islet-cell antibodies (ICA) and endogenous insulin secretion were studied in 46 Sudanese children (mean age 11.6 years) with newly diagnosed insulin-dependent diabetes mellitus (IDDM). Islet-cell antibodies were detected both by the indirect immunofluorescence (IF) and complement fixation (CF) methods. Endogenous insulin levels were measured as C-peptide concentration using radio-immunoassays. The degree of metabolic control of diabetics was judged by the presence of diabetic ketoacidosis (DKA) at onset, glycated haemoglobin (HbA1c) level and insulin requirement, expressed as dose per kg body weight per day, at the time of presentation. Twenty-nine patients (63%) had either IF-ICA or CF-ICA or both in their sera. These figures are significantly higher than those reported for African populations. Islet-cell antibody positive patients had significantly lower C-peptide concentration, higher HbA1c level, higher insulin requirement and higher prevalence of ketoacidosis at presentation. Furthermore, the C-peptide levels were higher in CF-ICA positive patients than in subjects who showed only IF-ICA positivity. Our findings show a clear association between ICA and severity of diabetes at clinical onset and also suggest that the presence of CF-ICA at or shortly after diagnosis of IDDM is indicative of preservation of some functioning beta-cell mass.

Protein-energy malnutrition in northern Sudan: clinical studies.

The medical history, clinical features and investigations of 145 children with kwashiorkor were compared with 113 marasmic kwashiorkor, 158 marasmic children and 186 nutritionally normal controls of similar age admitted to hospital in Khartoum. Factors in the group with protein-energy malnutrition (PEM) which could relate to aetiology include: a history of prolonged illness and anorexia, frequent and prolonged episodes of diarrhoea and recent measles. The delay in achievement of developmental milestones in PEM children probably reflects the frequent and chronic illnesses in this group. An episode of previous oedema was reported in 22 per cent of marasmic kwashiorkor, 12 per cent of kwashiorkor and 12 per cent of marasmic children. Though hair and mucosal changes and enlarged liver were more common in the marasmic kwashiorkor and kwashiorkor groups, they were also common in marasmic children. There was no significant difference in behaviour (apathy, irritability, anorexia) between kwashiorkor and marasmic children. The classical skin changes of kwashiorkor were only seen in the oedematous children. The mortality was 19 per cent in kwashiorkor, 35 per cent in marasmic kwashiorkor, and 14.5 per cent in the marasmic group. The major differences between marasmus and kwashiorkor children were that the kwashiorkor children were reported larger at birth, achieved more normal developmental milestones, were taller and had larger head circumference than the marasmic children. The implications of these findings in relation to aetiology are discussed.

The role of the village midwife in detection of high risk pregnancies and newborns.

The preliminary findings of a prospective study of perinatal, neonatal and maternal mortality carried out in a rural community of Sudan are reported. Out of 6275 deliveries monitored over a period of 3 years, 150 stillbirths, 167 neonatal deaths and 27 maternal deaths were observed. An intervention program to upgrade the skills of the village midwives started in the middle of the second year. There was a 25% reduction in the risk of unfavorable outcome of pregnancy (i.e. stillbirth and neonatal death) in the third year relative to the first 2 years. Peer review of the 40 village midwives who took part in the study revealed their tremendous potentials in mobilization of mothers as well as participation in primary health care. Their role in detection of high risk pregnancies and newborns cannot be overemphasized.

Whooping cough in Sudanese children.

The study describes the epidemiological and clinical features of whooping cough among eighty one Sudanese children (42 cases and 39 contacts aged below fifteen years) within 37 households who were under surveillance for a period of over six months. Using Khartoum Children's Emergency Hospital as the entry point, eleven patients were initially enrolled between July 1989 and August 1990 and led to the identification of another twenty six cases during home surveys. Subsequently, five of their contacts became secondary cases. The clinical criteria adopted by the Expanded Programme on Immunisation of the World Health Organization were used to identify the total of forty two cases included in the study. They were predominantly females (male: female ratio of 1:1.6), twenty (47.6%) were under five years of age and eight (19%) were infants. The attack rate was significantly higher among unimmunised infants (100%) compared to unimmunised children aged ten years and above (14.3%, p = 0.001). Half of the patients were from periurban areas, the majority (83.3%), were living in crowded households (room index > 5) and the primary immunisation rate was low (2.8%). Abnormal chest x-ray findings were detected in 26 (68.4%) patients and consisted mainly of bronchovascular thickening observed in 50%. During the follow-up period, a trend towards drop in patients' weight was observed. In four weeks, thirty (71.4%) children had a mean loss of 0.4 kg whereas eleven (26.2%) had static weight. A group of fifteen cases showed significant decrease in weight when compared to a control group of contacts that had been matched for age, sex and socio-economic status (p = 0.0001).

Microalbuminuria in young Sudanese patients with type 1 diabetes.

Overnight urinary albumin excretion (UAE) was measured in 51 patients, nine to 18 years old, with type 1 (insulin-dependent) diabetes mellitus and in 22 healthy subjects using radioimmunoassay. Thirteen diabetic patients (25.5%) had microalbuminuria defined as UAE rate between 20 and 200 microg/min. Eleven of these patients were over 13 years of age. This gives a frequency of microalbuminuria of 42% (11/26) in the diabetic children and adolescents in the age group 14-18 years. UAE rate was positively correlated with both age at diagnosis and duration of diabetes. Arterial blood pressure, systolic and diastolic, glycosylated hemoglobin (HbA1c) and insulin dosage U.kg- 1.day-1 were significantly higher (P<0.001) in the diabetic patients with microalbuminuria compared to the diabetic patients with normal UAE rate. Retinal changes were also more common in the microalbuminuric diabetic patients than in the diabetic patients without microalbuminuria (P<0.01). This study has revealed a high prevalence of microalbuminuria in young Sudanese patients with type 1 (insulin-dependent) diabetes mellitus and emphasized the importance of routine screening of diabetic children after the age of 12 years.

Measles: a disease that has to be eradicated.

The incidence of measles is on the decline but it still claims the lives of one million children annually worldwide. The devastating effects of the disease on the health and nutrition of children in developing countries and its high mortality are well documented. The rapid decay of maternal antibodies in infants in developing countries results in early susceptibility to the disease and hence the general recommendation to vaccinate at the age of 9 months. Sustained international efforts have raised global vaccination coverage rates to around 80% at which level it has remained static. Many countries in the western hemisphere have eliminated the disease by adopting aggressive strategies, which include one-off 'catch-up' mass campaigns to vaccinate all children aged 1-14 years, 'mop-up' campaigns targeting children who were missed during the 'catch-up' campaign, efficient routine vaccination services capable of reaching 90% of infants, strong surveillance activities, prompt outbreak response, and 'follow-up' campaigns every 2-4 years which target 1-4-year-old children. This success story coupled with the fact that measles has many biological features favouring eradication, and considering that it is a severe and lethal disease still prevailing in many areas, calls for immediate international adoption of eradication goals within a specified period of time.

Trimethoprim-sulphamethoxazole in the treatment of enteric fever.

Twenty-three patients with typhoid fever diagnosed by blood culture were treated with co-trimoxazole (trimethoprim/sulphamethoxazole, 1 :5) at a dosage of 10 mg trimethoprim/kg/day in two divided daily doses for 10 days. Twenty-two patients responded, the mean period to defervescence being three days and to relief of toxaemia being 1-7 days. Another nineteen patients with similarly proven typhoid were treated with chloramphenicol (100 mg/kg/day) in four divided daily doses for 10 days. Eighteen patients responded, defervescence occurring in an average of 4-1 days and relief of toxaemia in a mean of 2-6 days. None of the patients included in the study developed complications, relapses or became a convalescent carrier during the period of observation.

Morbidity patterns among under-five children in a rural community in Sudan.

This paper presents preliminary findings about morbidity observed in a prospective epidemiological study in a village community near Khartoum during 1977-1979. A total of 293 under-five children in 310 households were followed up for two years. Each household was visited twice monthly and information of the disease pattern was collected. Cough, fever and diarrhoea were found to be the commonest cause of morbidity. The average incidence being 296, 292 and 217 episodes respectively per 100 children per year. Vomiting, skin disease and conjunctivitis occurred at a much lower rate. Measles was observed in 14% of children under one year of age. The incidence of whooping cough was low an no outbreak occurred during the two years of observation. The seasonality of various diseases, their severity and age distribution is discussed and compared over the two year period.

Tracheobronchial foreign bodies: a review of children admitted for bronchoscopy at King Fahd Specialist Hospital, Al Gassim, Saudi Arabia.

This is a review of 147 patients suspected of foreign body (FB) inhalation, admitted to King Fahd Specialist Hospital in Al Gassim, Saudi Arabia from July 1989 to December 1994. Age, sex, foreign body type and site, presenting symptoms and signs, radiological findings, diagnosis and complications are analyzed and discussed. All foreign bodies were removed by rigid bronchoscopy under general anaesthesia. The study highlights the magnitude of the problem in the region and reviews the clinical presentation of patients who have inhaled an FB and recommends bronchoscopy as a means of early diagnosis and management.

Assessment of gestational age in Sudanese newborns.

Gestational age was assessed in 200 Sudanese newborns using the method of external superficial characteristics. Breast size, skin texture and ear firmness were found to be the best. Skin colour was not found to be of value.

Factors associated with high risk of perinatal and neonatal mortality: an interim report on a prospective community-based study in rural Sudan.

In a community-based prospective study, 6275 deliveries resulting in 6084 livebirths, 150 stillbirths (SB) and 167 neonatal deaths (NND) were monitored over a period of 3 years. The risk of an unfavourable outcome (SB or NND) in multiple pregnancies was more than ninefold that of singletons. Teenage mothers and those over 34 years of age ran nearly twice the risk of having an unfavourable outcome of pregnancy compared with mothers aged 20-29 years. First pregnancy and grand-multiparity (greater than eight previous pregnancies) carried a similar risk of an unfavourable outcome compared with mothers with 1-4 previous pregnancies. The most serious risk factor was the adverse outcome of the previous pregnancy. Compared with mothers whose last outcome had resulted in a livebirth surviving at least 30 days, mothers with a previous SB had seven times the risk (adjusted for age and parity) of SB and more than twice the risk of NND in the current pregnancy. Maternal illiteracy was associated with significantly higher risk of NND, and this rate decreased with increasing years of education. Frequency of antenatal visits had a marginally significant effect on the SB rate. Socioeconomic factors, diet and iron supplementation during pregnancy did not seem to affect the outcome.

PIP: Between March 1985 and April 1988 in a rural community in Sudan, a prospective study was conducted to determine the factors linked to perinatal and neonatal mortality. There were 6275 pregnancies and 6150 singleton births, 124 pairs of twins, and 1 set of triplets. The multiple pregnancy rate was 19.9/1000 deliveries. Pregnancy outcomes included 6084 live births surviving more than 30 days, 150 fetal deaths, 124 early neonatal deaths, and 43 late neonatal deaths. When the researcher controlled for age and parity, multiple pregnancies carried a higher risk of still birth, perinatal mortality, and neonatal mortality than did singleton pregnancies (relative risk [RR] = 6.1, 8.9, and 12.3, respectively; p 0.0001). Poor pregnancy outcome was 1.8 times more likely for teenage mothers than for 20-29 year old mothers (p 0.0003). First pregnancy and grandmultiparity ( 8 previous pregnancies) were associated with a higher risk of perinatal mortality when compared to mothers of parity 1-4 (RR = 1.9 [p 0.001] and 1.8 [p 0.01], respectively). A poor outcome of last pregnancy was the most important risk factor for neonatal death of current pregnancy (X2 = 55 when adjusted for multiple pregnancies and 36.5 when adjusted for age, parity, and multiple pregnancies; p 0.0001). The risk was highest when the last pregnancy outcome was stillbirth (RR = 6.9; p 0.001). Mothers with a previous stillbirth faced a 2.4-fold increased risk of neonatal death for the current pregnancy (p 0.001). Perinatal mortality rates fell as the number of years of full-time maternal education increased (p = 0.02 for the trend). Education mainly had an effect on reducing neonatal deaths (X2 for trend = 5.3 [p 0.05] vs. 1.8 for perinatal deaths and 1.1 for stillbirths). The frequency of prenatal visits had only a limited significant effect of reducing stillbirths (p = 0.05) and no effect of reducing perinatal and neonatal deaths. Household income, diet, and iron supplementation during pregnancy did not affect pregnancy outcome.

A new focus of endemic goitre in the Sudan.

The prevalence of goitre in the town of Kosti, Central Sudan and the city of Khartoum was investigated on account of the increasing number of goitrous patients in the wards and out-patient clinics of Khartoum Hospital coming from the county of Kosti. The frequency of goitre among 7173 school children from Kosti was 74.8%, and was higher in girls (82.1%) than in boys (67.3%). The frequency among 7075 school-children of Khartoum was 17.5%. The mean urinary iodine excretion in subjects from Kosti was significantly lower (41.8 micrograms/g creatinine) than in those from Khartoum (83.6 micrograms/g creatinine) (p less than 0.001). The water content of iodine in Kosti was low (0.1 micrograms/1). There were no significant differences in the mean serum concentrations of triiodothyronine, thyroxine and thyroid stimulating hormone (TSH) between goitrous and non-goitrous subjects from Kosti. The mean serum level of TSH was higher in goitrous subjects from Kosti (5.2 +/- 1.4 mU/1) than in non-goitrous subjects from Khartoum. These data indicate a high prevalence of goitre in Central Sudan, mainly attributable to iodine deficiency, a fact which has not previously been recognized. Recent environmental goitrogenic factors might have modified the adaptation of the thyroid gland and promoted the occurrence of goitre.

Prophylaxis and treatment of endemic goitre in Western Sudan with intramuscular iodized oil.

A single injection of iodized oil was administered intramuscularly in a dose of 0.2-2 ml (475 mg iodine per ml) to 383 children from the villages of Kas and Dibbis of the Darfur region in Western Sudan, where goitre is prevalent. After one year the prevalence of goitre had declined from 76% to 49.6%. Of the goitrous children, 81.1% showed either complete resolution of goitre or definite regression of its size. None of the nongoitrous children developed goitre and none of the existing goitres became larger. No cases of hyper- or hypothyroidism were observed. The full 270 children were followed up for four-and-a-half years after treatment and compared with untreated controls from the same area. The prevalence of goitre was significantly lower in the treated than in the untreated group. In treated children the mean urinary iodine excretion three-and-a-half years after treatment was 188.7 micrograms/g creatinine. This was significantly higher than in the untreated group (P less than 0.001). One year later the mean urinary excretion of iodine in the treated children had decreased to 87.1 micrograms/g creatinine. There was no difference in the mean serum values of T3 and T4 in the treated and untreated groups. The level of thyroid stimulating hormone was significantly lower in the treated [mean (S.D.) = 3.5 (0.9)] than in the untreated children [6.0 (3.5)]. It is concluded that a single injection of iodized oil is safe and effective in prevention of goitre development, reduces goitre size and maintains a sufficient iodine supply to prevent goitre for at least four-and-a-half years in children from goitre-endemic areas in Western Sudan.