Resurgence of Intestinal Parasitic Infections in the United Villages Region, Northern Khartoum state: Impact of armed conflict and water supply disruption

Abstract

Background

Intestinal parasitic infections (IPIs) are a silent struggle affecting people globally. Their impact is particularly devastating in developing countries like Sudan, a sub-Saharan African country where the healthcare system was already on the brink; the eruption of a devastating war has resulted in many outbreaks of infectious diseases. This study sheds light on the distressing resurgence of Intestinal parasitic infections (IPIs) amidst the armed conflict and siege in the United Villages Region, Northern Khartoum State, a stark reminder of the human cost of such crises.

Methods

This cross-sectional study was conducted in two resource-limited community clinics, which provided basic healthcare from July 1, 2024, to October 31, 2024. The study included 1,500 patients who presented with abdominal complaints and diarrhea. Each patient was asked to provide a stool sample for a general test.

Results

Among the 1,500 study participants, 200 (13.3%) had one or more intestinal parasitic infections (IPIs). Of these, 115 were females (57.5%) and 85 were males (42.5%). The most common intestinal parasite identified was Entamoeba histolytica (53%, n = 106), followed by Giardia lamblia (42.5%, n = 85). Mixed infections were found in eight cases (4%), involving both E. histolytica and G. lamblia, and in one case (0.5%), involving G. lamblia and Schistosoma mansoni. Most participants reported using Nile water (77.5%, n = 155), followed by well water (17.5%, n = 35). Few used a combination of Nile and well water (5%, n = 10).

Conclusions

Intestinal parasitic infections (IPIs) surged concurrently with armed conflict, which left a collapsed healthcare system, water shortages, and massive contamination of water sources. The calculated prevalence of 13.3% underestimates the actual burden due to many complications that prevent many people from reaching the health center. This picture reveals the vulnerability of such a community amid war; the information may be useful for future rehabilitation processes.

Trial registration

Not applicable.

Introduction

Intestinal parasitic infections (IPIs) are among the most prevalent neglected tropical diseases (NTDs), particularly affecting impoverished populations across Africa [1, 2]. These infections pose a significant public health challenge due to their widespread distribution and the substantial morbidity and mortality they cause [3, 4]. Broadly, intestinal parasites are categorized into two main groups: protozoa and helminthes [2]. Among these, soil-transmitted helminths (STHs) represent a substantial burden, afflicting millions of individuals worldwide, with a disproportionate impact on resource-limited settings [5].

The health consequences of these parasitic infections are predominantly the result of chronic, untreated infections that can lead to severe health complications. Such complications include malnutrition, iron-deficiency anemia, stunted growth, and cognitive impairments—especially among children [6]. While many infected individuals remain asymptomatic, heavy parasite burdens often manifest through gastrointestinal symptoms, which may include abdominal cramps, persistent diarrhea, nausea, and vomiting [7]. These clinical signs not only impair individual quality of life but also contribute to broader public health concerns by perpetuating cycles of disease, malnutrition, and developmental delays.

Globally, IPIs represent a persistent and critical public health issue. According to recent statistics from the World Health Organization (WHO), over 1.5 billion people—approximately 24% of the total human population—are infected with these parasites [2]. The majority of affected individuals reside in low-income countries where inadequate sanitation, poor water quality, and limited healthcare infrastructure facilitate ongoing transmissions [2]. Protozoal infections such as Giardia lamblia, Entamoeba histolytica, and Cryptosporidium spp., are among the most common intestinal protozoa responsible for diarrheal diseases in developing nations. These pathogens share common transmission pathways, primarily through the ingestion of contaminated water and food sources [8, 9].

Many of these parasites, including E. histolytica, G. lamblia, and Schistosoma mansoni, are transmitted via fecal-oral routes or through contact with contaminated water sources. They tend to thrive in environments characterized by inadequate sanitation and poor water management—conditions frequently encountered in impoverished communities with collapsed basic services. Such adverse environmental factors sustain the cycle of infection, leading to persistent and often recurrent cases of illness that burden affected populations and strain already fragile healthcare systems [8, 9].

Sudan is a vast tropical developing country with limited healthcare resources. Like most African countries, parasitic agents still draw the map of diseases throughout the country. Lack of basic infrastructure in healthcare and water supply for most people in the country with political and security instability has already created a very heavy disease burden, putting the limited healthcare system on the brink [4, 10–13]. The eruption of massive war was just the straw that broke the camel’s back, resulting in much suffering to the people, displacement, shortages of water and food, insecurity, and devastating outbreaks of infectious diseases, including, cholera, measles, rabies, and IPIs. IPIs may be asymptomatic or may manifest with abdominal pain, cramps, nausea, vomiting, diarrhea, and weight loss [14–17]. Wars and conflicts represent the most significant triggers of service collapses and shortages of basic necessities for the population, creating environmental conditions where disease-causing agents are actively transmitted. Intestinal parasites are among the most common disease-causing agents found in such fragile environments, where water and food supplies are compromised by poor individual hygiene measures and a lack of sanitation, perpetuating a cycle of transmission [18]. Consequently, the United Villages region, Khartoum North, recorded 200 cases of intestinal parasitic infections (IPIs) during the last rainy season (from July 1, 2024, to October 31, 2024).

This study aimed to assess the resurgence of IPIs in two medical centers in the United Villages region, Northern Khartoum. This informs the health, sanitation, living conditions, and public health status of the inhabitants. This knowledge can be used to control the outbreak and prevent future resurgence.

Methods

Study design, setting, and population

This community-based cross-sectional study was conducted during the autumn season (July 1 to October 31, 2024) at two centers in the United Villages Region, Northern Khartoum State, Sudan: Alfaki Hashim and Algaalyn medical centers. The United Villages Region contains six villages (Alfaki Hashim, Aljaaliyeen, Al Dabbah, Al Abdallab, Al Khalila South, and Al Khalila North). These are located approximately 38 km from the capital, Khartoum. The study area consisted of semi-rural communities and was situated less than 2 km from the River Nile (Fig. 1). The area had a total population of 25,000.

Fig. 1.

Location of the study area (United Villages Region), Northern Khartoum, Sudan

Data collection

A total of 1,500 patients who sought medical help at the two participating centers during the study period and presented with abdominal pain and diarrhea and underwent stool analysis as part of routine diagnostic evaluation were included.

Demographic and clinical data were collected through a structured pre-tested questionnaire that was initially prepared in English and then translated into Arabic (the participant’s native language) and reviewed for cultural and linguistic appropriateness. Collected variables included age, gender, water source, treatment received, and the macroscopic and microscopic finding of stool examination. To preserve patient confidentiality, all data were anonymized before analysis.

Laboratory work

All stool samples were collected in sterile, dry, and clean stool containers. Each container was properly labeled with individual’s full name and a unique serial number to ensure traceability. All procedures were conducted in accordance with Good Clinical laboratory practice (GCLP) guidelines to maintain quality, reliability and safety throughout the analytical phase [19].

Following collection, stool samples were first subjected to macroscopic examination. This involved careful visual inspection of the following characteristics: consistency of sample, color of the stool samples, presence or absence of blood or mucus, odor, foreign or undigested food particles, and presence of adult helminths or proglottids. Then, a direct wet mount was prepared from each fresh stool sample for rapid detection of motile protozoan trophozoites and helminth ova or larvae. Briefly, a small amount of stool (2 mg), particularly from the sample part that contained blood or mucus, was placed on the clean glass slide, followed by a drop of normal saline. The sample was observed for protozoa stages (cysts or trophozoites) and helminth eggs, then the wet preparation was covered with a coverslipand examined immediately under a light microscope using 10x and 40x objectives [20].

Statistical analysis

Descriptive statistics summarized demographic and clinical characteristics, with age categorized into six groups (< 5, 5–12, 13–17, 18–40, 41–60, and > 60 years). Descriptive statistics included mean ± SD, median, interquartile ranges [IQR], and proportions of demographic and clinical outcomes. The Gaussian distribution of the data was tested using the Shapiro-Wilks test. Where appropriate, mean [± SD] or median [interquartile range (IQR)] and related nonparametric statistics (Mann-Whitney U and Kruskal-Wallis) were used. For categorical variables, chi-square test (χ²) was used. Packages ‘ggplot2 and dplyr’ were used for visualization of the statistical analysis results, and packages (geodata, sf, ggplot2, ggspatial, and dplyr) were used for creating and visualizing a map of the study area. Statistical significance was established at a p-value less than 0.05. All analyses were performed using the R program 4.4.2 (Version 2025.05.1 + 513).

Results

This study enrolled 1,500 patients who had presented at the clinic with abdominal pain and diarrhea. Out of the 1500 microscopically examined stool samples, IPI diagnostic stages were revealed in 200 samples (13.3%), comprising 115 females (57.5%) and 85 males (42.5%) (Fig. 2). The mean age of the study participants was 30.7 ± 23.4 years, with a median of 25 years [IQR: 12–48.5], with a large proportion in the age group of 18–40 years (34%), followed by those aged 41–60 years (17%), < 5 years (14%), >60 years (13%), 5–12 years (12.5%), and 13–17 years (9.5%) (Table 1).

Fig. 2.

Distribution of Intestinal Parasitic Infections (IPIs) among individuals attending healthcare facilities in the United Villages Region

Table 1.

Demographic and clinical data of the study participant in the United Villages Region, Northern Khartoum, Sudan, 2024

Characteristic
Age (Mean ±SD, Median [IQR], Min: Max)	30.7±23.4, 25 [12–48.5.5], 1:89
Sex
Female	N= 115 (57.5%)
Male	N= 85 (42.5%)
Age group
< 5	N= 28 (14%)
5–12	N=25 (12.5%)
13–17	N=19 (9.5%)
18–40	N= 68 (34%)
41–60	N= 34 (17%)
>60	N= 26 (13%)
Water source
Nile	N=155 (77.5%)
Nile + well	N=10 (5%)
Well	N=35 (17.5%)
Type of treatment
Metronidazole	N=161 (80.5%)
Tindiazole	N=38 (19%)
Metronidazole + praziquantel	N= 1 (0.5%)
Macroscopic examination
Brown liquid	N= 25 (12.5%)
Brown soft	N=53 (26.5%)
Green liquid	N=13 (6.5%)
Red liquid	N= 38 (19%)
Yellow liquid	N= 42 (21%)
Yellow soft	N= 29 (14.5%)
Intestinal parasite
E._histolytica	N=106 (53%)
G._lamblia	N=85 (42.5%)
E._histolytica + G. lamblia	N=8 (4%)
G._lamblia + S.mansoni	N=1 (0.5%)
Recurrent infection	N=17 (8.5%)

Regarding water sources, the majority of study participants reported using Nile water (77.5%, n = 155), followed by well water (17.5%, n = 35) and a combination of Nile and well water (5%, n = 10). Regarding IPIs, the most common intestinal parasite identified was Entamoeba histolytica (E. histolytica) (53%, n = 106), followed by Giardia lamblia (G. lamblia) (42.5%, n = 85). Mixed infections were observed in 8 (4%) cases with E. histolytica and G. lamblia and in one case (0.5%) involving and Schistosoma mansoni.

Regarding treatment, the majority of patients (80.5%, n = 161) received metronidazole (for adults: 500 mg orally three times daily for 5–10 days; for children: 35–50 mg/kg/day orally divided into three doses for 10 days), followed by tinidazole (for adults: 2 g orally as a single dose for three days; for children: 50 mg/kg orally as a single dose for 3–5 days) (19%, n = 38), while one patient (0.5%) received a combination of metronidazole and praziquantel (for adults: 60 mg/kg total, given as 30 mg/kg twice in one day). The macroscopic examination revealed that the most frequent stool consistency was brown soft (26.5%), followed by yellow liquid (21%), red liquid (19%), yellow soft (14.5%), brown liquid (12.5%), and green liquid (6.5%). Recurrent infections were observed in 8.5% (n = 17) of patients (Table 1).

E. histolytica was the most frequent IPI detected in older aged groups > 60 years (73%), followed by those aged 41–60 years (61.8%), aged under 5 years (60.7%), aged 13–17 years (47.4%), aged 18–40 years (47%), and aged 5–12 years (32%), while G. lamblia was more common in those aged 5–12 years (60%), followed by those aged 18–40 years (50%), aged 13–17 years (47.4%), aged 41–60 years (35.3%), aged under 5 years (28.8%), and aged > 60 years (62.9%). Mixed infections were observed in 8 cases of E. histolytica and G. lamblia, mostly detected in 3 cases in those under 5 years, 2 cases in each of those aged 5–12 and 18–40 years, and one case in those aged 13–17 years, while the only case of G. lamblia and Schistosoma mansoni was observed in those aged 41–60 years. Moreover, our study observed that E. histolytica was more frequent in IPIs detected among female patients (57.4%) compared to male patients (47%). In contrast, G. lamblia was the most frequent IPI among male patients (48%), compared to female patients (38%). Regarding water sources and IPIs, both E. histolytica and G. lamblia were most commonly observed in the Nile, followed by well water. No statistically significant associations were found between IPIs and age group (p = 0.08), sex (p = 0.4), or water source (p = 0.2). Furthermore, E. histolytica mostly predominated in recurrent infection cases (88.2%) compared to G. lamblia (11.8%) with statistical significance (p > 0.05) (Table 2).

Table 2.

Distribution of intestinal parasites by age, sex, and water source and recurrent infection in the United Villages Region, Northern Khartoum, Sudan, 2024 (N = 200)

Characteristics	E. histolytica N= 106 (53%)	G. lamblia N= 85 (42.5%)	E. histolytica+ G. lamblia N= 8 (4%)	G. lamblia + S. mansoni N= 1(0.5%)	P = value
Age group
< 5	17 (60.7)	8 (28.8)	3 (10.7)	-	0.08
5–12	8 (32)	15 (60)	2 (8)	-
13–17	9 (47.4)	9 (47.4)	1 (5)	-
18–40	32 (47)	34 (50)	2 (1)	-
41–60	21 (61.8)	12 (35.3)	-	1 (0.5)
>60	19 (73)	7 (26.9)	-	-
Sex
Female	66 (57.4)	44 (38)	4 (3.5)	1 (0.9)	0.4
Male	40 (47)	41 (48)	4 (4.7)	-
Water source
Nile	86 (81.1)	64 (75.3)	4 (50)	1 (100)	0.2
Well	17 (16.1)	15 (17.6)	3 (37.5)	-
Nile + well	3 (2.8)	6 (7.1)	1 (12.5)	-
Recurrent Infection	15 (88.2)	2 (11.8)	-	-	>0.05

Furthermore, our study reveals that female patients had a slight predominance in recurrent cases (52.9%) compared to males (47.1%). The age distribution of recurrent infection showed the highest rates among older patients aged 41–60 and > 60 years (29.4%), followed by those aged 18–40 years (23.5%) and those aged under 5 years, 5–12 years, and 13–17 years (5.9%). Interestingly, all recurrent infections reported in this study were detected in Nile water (Table 3).

Table 3.

Distribution of recurrent IPIs by age, sex, and water source

Recurrent infection (N = 17)
Gender
Female	N= 9 (52.9%)
Male	N= 8(47.1%)
Age group
< 5	N= 1 (5.9%)
5–12	N=1 (5.9%)
13–17	N=1 (5.9%)
18–40	N= 4 (23.5%)
41–60	N= 5 (29.4%)
>60	N= 5 (29.4%)
Water source
Nile	N=17 (100%)
Nile + Well	-
Well	-

Discussion

The ongoing conflict in Sudan, which erupted in April 2023, has profoundly exacerbated existing health challenges within the country [21, 22]. This in turn created a dire environment conductive to the resurgence and spread of infectious disease, particularly parasitic infections [23, 24]. The disruption of healthcare infrastructure, coupled with restricted access to clean water, sanitation, and healthcare services due to widespread violence, has rendered vulnerable communities extremely susceptible to outbreaks of diseases such as Cholera, dengue fever, viral conjunctivitis and Intestinal Parasitic Infections (IPIs). These outbreaks are compounded by the accumulation of environmental hazards, contaminated water sources, exposure to sewage, and proliferation of disease vectors like flies, that collectively drive the transmission dynamic of these infections [14, 25, 26].

Epidemiologically, understanding the prevalence and distribution of IPIs within such fragile settings is critical for accurate risk assessment and the formulation of targeted intervention strategies. Accordingly, this study was conducted in a small town located north of Sudan’s capital, Khartoum, during a period of ongoing conflict. The community of approximately 25,000 residents was effectively under siege, with control of the area held by the Rapid Support Forces (RSF). The war had led to a complete collapse of the local healthcare system, leaving only two small clinics operating with severely limited resources amid a highly dangerous security environment. Essential infrastructure had been destroyed or rendered inaccessible; residents were deprived of reliable access to clean water sources. The Nile River, traditionally the community’s primary water source, became increasingly contaminated due to conflict-related disruptions. The surrounding environment was often littered with human remains, and many residents had lost their sewage systems, resorting to open defecation along the riverbank or within the vicinity. No water treatment or sanitation measures were implemented for the collected water or the containers used for storage. This environment, characterized by widespread filth and stagnant water, facilitated a significant surge in fly populations, which are known to play a major role in the transmission of infectious agents, further exacerbating the risk of disease outbreaks in the region.

This study was conducted in two resource-limited clinics that provided essential healthcare for people in a complicated environment. During that period, the center received 1,500 patients with abdominal pain and diarrhea, for whom a general stool test was performed, in addition to other available laboratory tests when indicated. On this occasion, many investigated patients were suffering from abdominal complaints and laboratory findings of different IPIs. This study offers valuable insights into the epidemiology and clinical presentation of IPIs among 200 patients, based on both clinical and diagnostic laboratory findings. This study enrolled 1500 patients, out of whom 200 cases of IPI were revealed. This distribution of IPIs, at 13%, is significant, we believe, is just the tip of the iceberg, as not all people were able to reach the clinic. Some people suffered these infections in silence; they used whatever was available for them as treatment, i.e., traditional herbal therapies like Acacia nilotica and Adansonia digitata [27]. Some people were taking their own prescriptions of metronidazole and other antibacterial agents within their reach. The findings painted a very sad picture of widespread contamination of the food and water supply with human feces, indicating a severely compromised environmental situation where contamination is present in nearly every food and water source.

Interestingly, the patients predominantly affected were females (57.5%), with a mean age of 30.7 years, reflecting a community where working-age adults and children are significantly impacted. Moreover, the stark predominance of E. histolytica (53%) and G. lamblia (42%) aligns with the global pattern of protozoan parasitic infections, which cause significant diarrheal morbidity, particularly in resource-limited settings with potential water safety challenges [2, 8, 9]. The observation of distinct age preferences, with E. histolytica being more common in older adults (>60 years (73%) and 41–60 years: 61.8%) and younger children < 5 years (60.7%), while G. lamblia peaked in school-aged (5–15 years: 60%) and younger adults (18–40 years: 50%), underscores the complex interplay between age and parasite biology, host immunity, and route of exposure. This suggests that E. histolytica may exploit weakened immune systems in very young or elderly individuals, reflecting the chronicity of the disease. O-n the other hand, G. lamblia transmission may be amplified among school-aged children, likely due to their typical behaviors and hygiene practices at this age.

A particularly concerning finding is that recurrent infection was noted in 8.5% of cases, predominantly involving E. histolytica (88.2%). This pathogen has the ability to cause invasive disease and potentially form cysts that evade available treatment or lead to reinfection, posing a critical challenge to patients and community well-being, leading to repeated episodes of debilitating diarrhea, abdominal pain, malnutrition, and loss of productivity [28]. All recurrences occurred among patients using Nile water, highlighting this source as a major hotspot. This points strongly towards ongoing environmental contamination of this major waterway as a persistent source of exposure for both E. histolytica (81.1%) and G. lamblia (75.3%). Although the link between the water source and initial infection was not statistically significant (p = 0.2), the exclusive association with recurrence suggests ongoing contamination and repeated illness for those dependent on Nile water. This translates directly to human suffering; individuals relying on this vital resource face repeated bouts of infections, hindering their ability to work, care for families, or attend school [29, 30].

Moreover, our study noted a subtle gender disparity in IPIs prevalence; E. histolytica was slightly more frequent in females (57.4% vs. 47% in males), while G. lamblia showed the opposite trend (38% in females vs. 48% in males). Although not statistically significant (p = 0.4), this pattern warrants consideration. It could reflect gender-based differences in water collection or usage roles (women and children often bear the primary responsibility for fetching water, potentially increasing exposure), domestic care activities involving fecal matter, or occupational exposure. Recurrent infection also showed a slight female predominance (52.9%). Understanding these nuances is essential for tailoring public health interventions. The heavy reliance on the Nile (77.5%) and well water (17.5%) as primary water sources underscores a critical vulnerability; the high prevalence of waterborne protozoan parasites, such as E. histolytica and G. lamblia, directly implicates inadequate water, sanitation, and hygiene (WASH) infrastructure. The lack of a statistically significant association between water source and initial parasite type (p = 0.2) could reflect widespread contamination affecting both water sources. However, the concentration of recurrence solely among Nile users strongly suggests this source represents a particularly high risk for persistence of E. histolytica transmission. Therefore, communities dependent on the Nile are not just exposed once but face a relentless threat of reinfection, trapping them in a cycle of illness [29]. The diverse stool consistencies observed reflect the varying pathologies caused by these protozoa, ranging from mild dysentery to severe diarrhea. The predominance of metronidazole and tinidazole treatment aligns with current guidelines for the treatment of amoebiasis and giardiasis [31, 32]. While the single case that required combination therapy of metronidazole and praziquantel highlights the complexity introduced by co-infections like Schistosoma mansoni, adding another layer of morbidity to an already burdened patient.

One of the main strengths of this study is that it was conducted in resource-limited community healthcare centers located in semi-rural communities. These settings represent an ideal context for investigating IPIs, as such regions often exhibit higher disease burdens due to limited access to preventive measures and healthcare infrastructure; in particular, the study area (United Villages region) had been under an extended blockade imposed by RSF militia during the ongoing war in Sudan. This siege not only exacerbated the already fragile healthcare system but also created conditions of extreme vulnerability, making the population particularly susceptible to neglected tropical diseases (NTDs). The fact that the study was conducted in such difficult conditions adds to its value, as it captures epidemiological data from typically underrepresented and high-risk individuals. However, a significant limitation must be acknowledged. The RSF militia’s blockade probably had an impact on the overall estimated disease prevalence since it made it difficult for many symptomatic patients to gain access to the healthcare facilities where the study was carried out due to the limited movement of people in and out of the affected region. This limitation may have led to an underrepresentation of the true case number, and therefore the reported prevalence may not accurately reflect the actual magnitude of the disease transmission within the broader community. Furthermore, it is crucial to remember that not all possible factors that can affect the prevalence of IP infections were taken into account in this study. Therefore, it is recommended that future research be carried out as generalized studies and thorough examination of all potential factors that can influence the occurrence of IPIs.

Conclusion

A hotspot of IPIs transmission was revealed during conflict in a village area north of Khartoum, Sudan. The cycle of transmission includes contamination of water resources and a surge of flies in the region. The pattern of infectious agents revealed E. histolytica as the most encountered, followed by giardiasis with cases of co-infection. Water shortages, lack of water treatment infrastructure, contaminated water resources, and the resurgence of flies amid an armed conflict and siege in this region resulted in a massive outbreak of IPIs. Any future rehabilitation programs should consider the health issues of chronic giardiasis and possible cases of liver amebiasis. Sustainable improvements in water treatment at the source and point of use, as well as sanitation facilities and hygiene education, are paramount to breaking the transmission cycle of parasites.

Author contributions

NSM and AA were responsible for the study design and supervised the data collection. OTO and SIM performed the data collection and laboratory work. NMH performed the data analysis and visualization. NMH, SIM, EES, AA, MEH, CMM, and NSM drafted and revised the manuscript. All the authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study complied with the Declaration of Helsinki. This study was reviewed and approved by the Ethics Committee of the Faculty of Medical Laboratory Sciences of Omdurman Islamic University (OIU). Informed consent was obtained from all participants and/or their legal guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.