Pattern of infectious diseases among Khalwa (Quran boarding school) students in Khartoum State, Sudan

Abstract

Khalawi are one of the most ancient non-governmental educational institutions that are commonly found all over Sudan playing a major role in the Sudanese society. The majority of Khalwa students are children. This study was part of a mixed methods project, conducted by Khartoum Medical Students’ Association, aiming to investigate the health status of Khalwa students. It is a cross-sectional study carried out in Mustafa Alfadni Khalwa, Sharg Al-Neel suburb in Khartoum State. The participants were clinically assessed by a doctor and data were collected by using a data entry tool made specially to screen for major infectious diseases among students. The results showed a mean age of 13.7 years. Most of the students (47.7%) were originally from Darfur, and 27.5% of them had only Khalwa education. Respiratory clinic results revealed that 10% were complaining of cough, and 3.4% were diagnosed with pneumonia. Additionally, 44.6% of the students had tinea capitis and 21% had scabies. On examination, 2.3% and 1.1% had mild splenomegaly and hepatomegaly, respectively. Infectious conjunctivitis and trachoma were reported among 11.7% and 10.9%, respectively. Blood films for malaria were positive in 51.3%. Macroscopic and microscopic haematuria was evident among 13.4% and 10.8% of the participants, respectively. Stool examination results showed that 1.4% of the students had worms, 1.5% had ova and 18.8% had red blood cells in stools. Infectious diseases are very common among Khalwa students and their living environment is facilitating the transmission of these diseases. Agent control and sanitation improvement are crucial to decrease such infectious diseases.

INTRODUCTION

Khalwa (singular of Khalawi) is one of the most ancient non-governmental educational boarding institutions in Sudan [1]. Throughout history, several transformations have been made and numerous models of Khalawi have emerged. However, they all have the basic fundamental system of residential schools that teach students the Quran, as well as some sorts of primary education, allowing the graduates to pursue further formal education in the governmental system. Khalawi are widely spread in Sudan, involving many students and playing major spiritual, social and educational roles in the Sudanese society [2].

Several studies have investigated the nutritional and health status of Khalawi students, revealing a high prevalence of anaemia and night blindness [3-5], in addition to various infectious diseases including schistosomiasis and fungal infections [1]. Since the majority of Khalawi students are children, their health has a major role in their educational development, and these deficiencies and diseases might negatively affect their development and school performance [6,7].

This study was part of a mixed methods project, conducted by the Khartoum Medical Students’ Association, that aimed to investigate the health status of Khalawi students, plan for the effective measures and interventions that will improve their health and nutritional conditions and later assess the effectiveness of these interventions. In this study, the patterns and trends of various infectious diseases among Mustafa Alfadni Khalwa students have been demonstrated.

MATERIALS AND METHODS

This is a cross-sectional study conducted at Mustafa Alfadni Khalwa, located in Sharg Al-Neel suburb in Khartoum State. Data collection was conducted from 30 September 2017 to 6 October 2017. This Khalwa was selected because it is a popular Khalwa in the region and it recruits students from different regions of Sudan and neighbouring countries. The total coverage sampling technique of the Khalwa students was adopted. Accordingly, a total of 132 students participated in this study. All students in the Khalwa in the study period were enrolled, excluding the ones who refused to participate.

A data collection sheet was specially designed to screen for major infectious diseases among the students. It comprised history taking, physical examination and laboratory investigations. Socio-demographic data of the children were collected. The children answered questions about their age, state of origin, educational level, the length of the period they stayed in Khalwa and their parents’ level of education.

Firstly, the student was interviewed by a paediatrician who asked about the symptoms of common diseases (malaria, pneumonia etc.) and full physical examination was conducted by him. Then, the student got interviewed and examined by a dermatologist for skin lesions and rashes and history of skin problems. Based on that, clinical diagnosis of skin abnormalities was made. Then, an ophthalmologist took history about eye problems and examined the eyes of each student, using a torch and an ophthalmoscope, for common ophthalmic infections. After that, each child was examined by an otolaryngologist for ear, nose and throat infections. An otoscope, a torch and an indirect laryngoscope were used in this examination. Based on the signs and symptoms, a clinical diagnosis was made. Case definitions for the infections were as follow: pneumonia was defined as an acute disease episode with cough or difficult breathing combined with fast breathing with age-specific cut-off values for increased respiratory rate; tinea capitis as the ones which had clinical signs (such as scalp purities, scalp scaling, patchy or discrete alopecia); tinea cruris as a pruritic ringed lesions (erythematous, scaly and sharply demarcated) in the groin, possibly with central clearing; scabies as an individual who has intense itching and superficial irregular burrow tracts that typically appear in folds of the skin; and infectious conjunctivitis as irritation, photophobia and watery discharge. Trachoma was assessed according to the WHO definitions on the five stages of trachoma, follicular inflammation, intense inflammation, eyelid scaring, in-turned eyelashes and corneal clouding.

Blood samples were collected and malaria was tested using thick and thin blood film stained with Giemsa under the microscope. Urine samples were collected and examined macroscopically and microscopically for pus cells, red blood cells (RBCs), yeast cells and ova after it was centrifuged. Stool samples were collected and examined macroscopically for colour, reaction, consistency, mucous, worms and blood; and microscopically for pus cells, RBCs, ova, worms and motile bacteria. All these procedures were carried out by senior laboratory technicians. The collected data was entered and analysed using SPSS software version 23. Chi-square test was used to test for the association between various variables of the study, and p-value of less than 0.05 was considered statistically significant.

RESULTS

The mean age of the 132 students who participated in this study was 13.7 ± 2.7 years. Most of them (47.7%) were originally from the region of Darfur. The majority (70.2%) had primary level of education, and 27.5% had only Khalwa education and never had any formal education. The mean number of years spent by the children in this Khalwa was 1.58 years.

Respiratory assessment revealed that 10% were complaining of cough, and 3.4% were diagnosed with pneumonia. Additionally, dermatological assessment revealed that 44.6% of the students had tinea capitis (Figure 1). Tinea cruris was prevalent among 2.6% of them and 21% had scabies. Furthermore, 4.2% had chicken pox. None of the children in this study had measles.

Figure 1.

Infectious diseases among Khalwa students.

On examination, 7.8% of the participants had fever and 2.3% and 1.1% had mild splenomegaly and hepatomegaly, respectively. Moreover, enlarged cervical lymph nodes were reported among 8.3% of them. Additionally, 4.9% of the children presented with oral thrush and 16% with tonsillitis. Infectious conjunctivitis and trachoma were reported among 11.7% and 10.9%, respectively.

Regarding the laboratory findings, blood films for malaria were positive in 51.3% of the students. Macroscopic and microscopic haematuria was, respectively, evident among 13.4% and 10.8% of the participants. Pus cells, yeast cells and ova were found in 12%, 3.7%, and 6% of the children’s urine samples, respectively. In addition, stool examination results showed that 1.4% of the students had worms, 1.5% had ova and 18.8% had RBC stools. Furthermore, 50.8% of the stool samples were positive for motile bacteria, and Schistosoma haematobium eggs were detected in 6% of the urine samples.

Association tests (Table 1) were carried out to explore the association between having a positive blood film for malaria, and having motile bacteria in the stool, with the presence of tinea capitis, trachoma and tonsillitis, but no association was found.

Table 1.

Association tests results.

Infection	p values
	Having a positive blood film for malaria	Having motile bacteria in the stool
Tinea capitis	0.742	0.696
Trachoma	0.311	0.306
Tonsilitis	0.481	0.313

DISCUSSION

This study investigated the patterns and trends of various infectious diseases among Mustafa Alfadni Khalwa students. Nearly half of the students had tinea capitis and 21% of them had scabies. Additionally, 16% of them had tonsillitis and 11.7% had infectious conjunctivitis. Moreover, more than half of the participants had positive blood films for malaria and 50.8% of the students stool samples were positive for motile bacteria.

Malaria has been one of the most important public health issues in Africa, particularly in school-aged children, owing to its influences on cognitive function and absence from school as it is thought to be responsible for 13%-50% of school absences for medical reasons [8]. In the present survey, laboratory evidence of malaria was detected in over half (51.3%) of the children, which is comparable to rates detected in schoolchildren in Tanzania [7], Congo [8] and Yemen [9] with prevalence estimates ranging from 0.1 to 53%, 21.6 to 77% and 12.8 %, respectively. However, seasonal and geographical variations may play a significant role in the determination of malaria prevalence.

Regarding dermatological diseases, we found a 44.6% prevalence of tinea capitis. This high prevalence could be due to overcrowdedness and sharing fomites like combs and hats. In a study in Ethiopia, 62.3% of the schoolchildren under study had some sort of dermatophytosis and 90.3% of them had tinea capitis. In another school, 45.8% of the student had dermatophytosis and 91.2% of them had tinea capitis [10]. When compared to a study conducted in Turkey, which is economically less challenged, a prevalence of 0.3% was found [11]. In Nigeria, 8.7% were found to have tinea capitis [12]. In a previous study conducted in Sudan on 8,443 students, 272 (3.2%) had tinea capitis; the study goes on to state that the majority of cases are in boarding schools, and when compared to daytime schools, a ratio of 4-5:1 favoured boarding schools [13].

21% of the students in this study were diagnosed with scabies compared to 17.8% in a study that was conducted in four Cameroonian boarding schools [14]. This is especially evident when compared to a study in Bangladesh in Islamic religious schools that found a prevalence of 61%-62% [15]. Our studies results were also higher than the results yielded by a study conducted among schoolchildren in Nigeria with a 13.3% prevalence rate [16]. Those results can be due to poor personal hygiene, overcrowdedness and poverty. The aforementioned studies also describe similar reasons.

In our study, 4.2% of the children had chicken pox. Ever since the introduction of its live attenuated vaccine in 1995, the disease’s prevalence rapidly declined worldwide, and so did the literature. However, the UNICEF in their 2017 humanitarian report in South Sudan reported 3,245 cases of chicken pox [17]. None of the children in this study had measles.

Schistosoma haematobium eggs were detected in 6% of the urine samples. The prevalence of urinary schistosomiasis is different throughout the states of Sudan. For instance, it is reported to be as high as 20% in Aljazeera state [18] and as low as 0% in New Halfa region [19]. It was also found to be 12% in Jabal Awlia in Khartoum state [20]. This is due to different epidemiological factors in these states, mainly the presence of nearby contaminated rivers, along with the availability of medical care and health education. Students in this Khalwa came from different states all over Sudan.

Urine microscopy detected the presence of significant pus cells among 12% of the students, most likely due to urinary tract infections. This is almost one-third of the prevalence found among students in Nigeria [21].

We measured the prevalence of two of the most common eye problems in children worldwide, trachoma, which is the commonest infectious cause of blindness in the world [22], and infectious conjunctivitis, a known public health issue in underdeveloped regions [23]. Trachoma was detected in 10.9% of the students. In the same way, the prevalence of this disease reaches more than 10% in many African countries [24-27]. This may be explained by the poor living conditions, single water source and increased fly (Musca sorbens) density in this religious institution. We also found a high prevalence of infective conjunctivitis (11.7%) amid these children. Significantly higher percentages were observed among children in rural areas of the Qinghai province and preschool aged students in the rural and suburban areas of Beijing (34.3% and 22.59%, respectively) [23,28] .

One of the limitations of this study is the small sample size which might affect the generalisability of its results. Another limitation is that most of the diagnosis of some diseases, e.g., scabies, was performed on clinical bases, and more sophisticated laboratory techniques are needed to diagnose such diseases.

CONCLUSION AND RECOMMENDATIONS

Infectious diseases are very common among Khalwa students and their living environment is enabling transmission of these diseases. Controlling these diseases is relatively easy but needs sincere efforts and commitment from the government and non-governmental organisations.

Water draining, agent control, improving sanitation and waste disposal systems of the Khalwa are very important to decrease growth and multiplication of bacteria and parasites and the vectors carrying them. Managing current cases is crucial to eliminate these diseases from the children and to stop its horizontal spread.

Health education and behavioural changes are keys to fight the dissemination of infectious diseases. Therefore, health education programme should be started. The effect of the intervention should be measured and altered to give the children the maximum possible benefit.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

FUNDING

This study was part of Phase 1 (screening phase) of Khalawi Health Promotion Project supported by Khartoum Medical Students’ Association (KMSA), Health Education Secretariat.

CONSENT TO PARTICIPATE

Informed consent was taken from the guardians of the students and oral assent was taken from each participant. Confidentiality of the participants was safeguarded during all the stages of this study.

ETHICAL APPROVAL

Ethical approval for this study was granted by Khartoum State Ministry of Health and performed according to their guidelines and regulations. Khalwa administration approved for the study to take place in their setting.