The Battle against schistosomiasis in the Gezira Irrigation Scheme in Sudan Mutamad Amin & Hwida Abubaker Ahfad University for Women Symposium on: Advances Parasito in the service of Mankind “ Symposium on: Advances in Parasitology “Education and Research in Parasitology in the service of Mankind “

Objectives of the Presentation --Identify the changing patterns of schistosomiasis infection over different political eras among the communities working in the Gezira Irrigation Scheme; -- To identify the factors influencing the changing patterns over time --Examine critically the different approaches to control schistosomiasis in the Gezira Scheme since its establishment in 1925 -- To identify the reasons behind the non sustainability of the control programmes.

Content of the Presentation Part one A brief history of the Gezira Irrigation Scheme Part two is the chronological review and analysis of the processes of intervention at different eras in the history of the project and what with the analysis as of what leads to its down pits. Brief factors led to the downfall Part three Part Three Options of Control to Attain Sustainability --Successful stories --Our integrative approach

Part One Brief History of Gezira Scheme

Map of Gezira and Gezira Scheme The Gezira (which means "island") Irrigation Scheme lies between the Blue and White Niles in the Gezira State, some 250 km. south to Khartoum. It occupies about five million feddans(1 feddan= 1.38 acres); of these only 3 million feddans are suitable for irrigation

The Gezira Scheme (Story) In 1911, cotton was planted on small experimental scale irrigation by pumps. --After cotton production proved successful, it was decided to establish a dam at Sennar which was completed in 1925. -- The Gezira Irrigation Scheme was initially financed by the Sudan Plantations Syndicate in London and later the British government guaranteed capital to develop it. --The Scheme was nationalized in 1950, and was operated by Sudan Gezira Board as a government enterprise (Hyslop, 1952).

The story behind The Gezira Scheme (Irrigation) --Water flows by gravity from the main canals, one for the Gezira and the other for the Managil Extension into major canals and from these to minor canals. -- Irrigation channels called abu-eshreens branch from minor canals at 300 meter intervals. -- Before irrigation by canalization the population was approximately 135, 000 (Elnagar, 1958). --The gradual implementation of the scheme throughout the Gezira region had been the cause of change in the composition of the population in the area.

The Gezira Scheme (Schistosomiasis) --Before the establishment of the Gezira irrigation scheme, no bilharzia was found among children from twenty villages in the middle of the Gezira (Jordan, 2000) ; --1926 1% of 4000 children examined had urinary bilharzia; within 30 months of the canals being completed Bulinus snails (intermediate host of urinary bilharzia) were found throughout the system. --12 months later Biomphalaria snails (intermediate host of intestinal bilharzia ) were widespread, 0.3 and 4.3% of local and non-local Sudanese were infected respectively compared with a prevalence of 14.3% in immigrants coming from all parts of Sudan

Pioneers in Fighting schistosomiasis in Sudan Prevention and control of schistosomiasis in the Sudan had been intensified by the establishment of the Gezira irrigation Scheme in 1925 and the successful treatment of schistosomiasis by antimony tartarate as a result of the work of Christopherson in Khartoum hospital in 1918 . The health authorities ( SMS ) were well aware of the consequences of bilharzia in the Gezira irrigation Scheme – failure to prevent would be disastrous and probably irreversible ( Annual report of Health Services 1926, Sudan) . Christopherson 1918

Part two Chronological review

Control of schistosomiasis during the colonial era: 1925-1955 Objective of the programme was to reduce disease prevalence. Target community, agricultural workers and children Measures screening of workers and compulsory treatment of infected people snail control and health education. Results Between 1926 and 1935, 10,000 – 20,000 men were examined; the prevalence varied between 0.06 and 0.77% and among thousands of children screened, between 0.22 and 1.12 % were infected.The situation deteriorated after World War II and the intestinal bilharzia replaced urinary infection as the main problem in the Gezira (Stephenson, 1947) Sustainability The onset of the Second World War led to resources being shifted away from the control of bilharzia in Gezira in particular, and health care in Sudan more generally, towards fighting the war. (Stephenson, 1947)

From independence in 1956 to 1979 Objective control of transmission. Target: snail intermediate hosts and community Intervention: From 1956 to 1979 as a result of intensive control programmes for nearly thirty years included annual mass sulphation at 30 P.P.M.of copper sulphate followed by continuous low dosage of 0.125 PPM kept at head of major canals in small bags. Mechanical barriers were erected in the main canal to trap drifting snails.diagnostic and treatment teams toured the area periodically from one village to the other using thick smear films for diagnosis and antimony for treatment. Sustainability : This strategy was not sustained because of shorted of funds that resulted in limited snail control measures and increased population movements

1970 to 1979 London Khartoum Bilharzia Research Project During the Bilharzia symposium held in Addis Ababa in 1970 the lead author (Mutamad Amin) proposed to his PhD supervisor Professor George Nelson of the London of School of Hygiene and Tropical Medicine a joint collaborative research project in bilharzia between the London School of Hygiene and Tropical Medicine and the Ministry of Health, Sudan. Young British scientists will join with their counterparts Sudanese to gain experience in tropical medicine and the London School will provide logistic support for the project.

Blue Nile Health Project (BNHP) 1979-1990 The Blue Nile Health Project (BNHP) was established to control malaria schistosomiasis and diarrhoeal diseases in Gezira, Managil and Rahad Schemes, adopting a comprehensive integrated plan. Objective :to reduce prevalence of schistosomiasis to less than 10% Intervention tools: chemotherapy,water supply,sanitation,health education and snail control Target : communities of Gezira and Rahad States Results : schistosomiasis was reduced from 53% to 6% in Gezira State. Sustainability : The BNHP was a great success story in the history of control of water associated diseases. It received strong support from the president by issuing a presidential decree for its establishment and encourage the international donors to support the project.Further the discovery of the efficient drug,praziquantel had significant impact the prevalence and morbidity of schistosomiasis. Unfortunately this success could not be sustained and the mission was not accomplished in Managil zone as a result of lack of funds and dismantle of the project by the Federal Ministry of Health

. National Control Programme 2000 to date Objective : control of morbidity. Target: school children and the community Intervention: preventive chemotherepy During this era schistosomiasis spread in most states of Sudan including Khartoum State. The prevalence was estimated to be between 3.5% to 90% (Amin, 2012). Prevalence rates of 72.8% in males and 62.3% among females were reported in a village in the Gezira in 2006 and the overall prevalence of spleenomegly was found to be 35.8% (Saeed et al., 2006). Recent study showed a prevalence of 32% in children in Habiba Administration Unit,Gezira State. The sustainability of control activities conducted by the National Control Programme depends on donation of Praziquantel and availability of operational funds which are often not available. Further the Gezira Irrigation Scheme was dismantled by a government law adopted in 2005 and the administration was weakened.

summary All the control projects initiated in the Gezira Scheme since its establishment in1925, though achieved reductions in prevalence and morbidity but were not sustained. including the BNHP which had all the requirements ,highly qualified staff, generous budget ,political commitment and under continuous evaluation from WHO.The project was regarded as the most success story in the history of control of schistosomiasis.

Part Three Options of Control to Attain Sustainability Part Three Options of Control to Attain Sustainability --Successful stories --Our integrative approach

Reference of successful stories El Girba scheme (182,000acres) which was chosen for development of agriculture and resettlement of Wadi Halfa people who had to leave their areas in northern Sudan as a result of the establishment of Aswan High Dam, 25 model villages Manoun, 1979 showed that S. haematobium was non-existent amongst the migrant Nubians and instead contracted S.mansoni with a prevalence of only 8% in a period of about 20yares The Rahad Scheme (300.000) was kept Schistosomiasis free for more than 7 years in spite of the presence of Biomphalaria Pfeifferi, intermediate host of S.mansoni , and the presence of resident infected labour force together with the influx of infected seasonal cotton pickets. This was due to the excellent planning of villages and the efforts of the Blue Nail Heath project in the periodic destruction of snails and chemotherapy programmes. However in recent years evidence of active transmission was reported . Saudi Arabia Socio-economic development in most areas of Saudi Arabia, which has resulted in improved sanitation and water supplies and a significant increase in medical care and education has played a large part in the interruption of transmission (Ashi et al.,1989;Swailem, 1988)

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